natashalage
Expert
Hello coding community! We have a different opinion on how to code the case below: Cpt and Dx. We would like to hear your rational. Thank you very much for your help.
We both agree that with 76998 US and -22 for extra work, we disagree on Px and Dx.
Option 1: 59841-22 D&E, 76998 with dx O03.4-SAB 24 weeks
Option 2: 59821-22, 76998 with O36.4xx0 24 weeks, 59821- Treatment of missed abortion, completed surgically; second trimester
O03.4 Incomplete spontaneous abortion without complication
O36.4xx0- Maternal care for intrauterine death, not applicable or unspecified
PROCEDURE: Standard dilation and evacuation/D and E
CLINICAL INDICATIONS: . G2P0010 at 24+0d with fetal demise
She was seen yesterday on L&D where ..She had cervical preparation with Cervical osmotic dilators overnight ..
PROCEDURE: ... Dilation was assessed and found to be slightly inadequate. Dilation performed with Pratt dilators to 45 Fr. A 14 mm suction cannula was advanced and the amniotic fluid removed. Bierer forceps were used to transect the umbilical cord and to evacuate fragmented fetal parts and placenta. Sharp curettage was used to confirm an empty uterine cavity and suction aspiration was repeated. Throughout the procedure we were careful to pass the instruments carefully into the uterine cavity due to significant distortion from a posterior lower uterine segment fibroid.
Hemostasis was not satisfactory at the end of the procedure. Methergine and then TXA was given. An ultrasound revealed a thin uterine stripe. The posterior cervix was raw and did not become hemostatic after pressure and application of Monsel's solution. The cervix was whip-stitched from 6:00 to 9:00 with running locked 0-Vicryl. Additional Monsel's and pressure were applied and then hemostasis was satisfactory. All instruments were removed from the vagina and the patient was taken to the post-anesthesia recovery room awake and in stable condition. Products of conception were examined and noted to be complete.
INTRAOPERATIVE SONO: Indication for intraoperative sono: D&E performed with forceps.
SPECIMEN: products of conception were sent fresh, permanent to pathology. Small section of fetus and placenta were sent for microarray (SNP)
We both agree that with 76998 US and -22 for extra work, we disagree on Px and Dx.
Option 1: 59841-22 D&E, 76998 with dx O03.4-SAB 24 weeks
Option 2: 59821-22, 76998 with O36.4xx0 24 weeks, 59821- Treatment of missed abortion, completed surgically; second trimester
O03.4 Incomplete spontaneous abortion without complication
O36.4xx0- Maternal care for intrauterine death, not applicable or unspecified
PROCEDURE: Standard dilation and evacuation/D and E
CLINICAL INDICATIONS: . G2P0010 at 24+0d with fetal demise
She was seen yesterday on L&D where ..She had cervical preparation with Cervical osmotic dilators overnight ..
PROCEDURE: ... Dilation was assessed and found to be slightly inadequate. Dilation performed with Pratt dilators to 45 Fr. A 14 mm suction cannula was advanced and the amniotic fluid removed. Bierer forceps were used to transect the umbilical cord and to evacuate fragmented fetal parts and placenta. Sharp curettage was used to confirm an empty uterine cavity and suction aspiration was repeated. Throughout the procedure we were careful to pass the instruments carefully into the uterine cavity due to significant distortion from a posterior lower uterine segment fibroid.
Hemostasis was not satisfactory at the end of the procedure. Methergine and then TXA was given. An ultrasound revealed a thin uterine stripe. The posterior cervix was raw and did not become hemostatic after pressure and application of Monsel's solution. The cervix was whip-stitched from 6:00 to 9:00 with running locked 0-Vicryl. Additional Monsel's and pressure were applied and then hemostasis was satisfactory. All instruments were removed from the vagina and the patient was taken to the post-anesthesia recovery room awake and in stable condition. Products of conception were examined and noted to be complete.
INTRAOPERATIVE SONO: Indication for intraoperative sono: D&E performed with forceps.
SPECIMEN: products of conception were sent fresh, permanent to pathology. Small section of fetus and placenta were sent for microarray (SNP)