debellis59
Networker
Hi All
I have a patient who had a failed medical abortion (other provider) and so she came to us with abdominal pain. We found retained products of conception ... I am at a loss on how to code this. We don't do abortions where I work, we deal only with SAB, IUFD, MAB, etc. I used 59812 for treatment of incomplete abortion ... and with POC still there that was the only CPT that fit. The diagnosis I used O07.4 Failed attempted termination of pregnancy without complication, although I didn't like it. Anyway, it was denied, not unexpectedly. There just don't seem to be any really decent diagnoses that would go with what this scenario is. We're being told to bill the State (Oregon) for the abortion but the codes are for induced abortions ... we're just dealing the POC that were not adequately removed by the other provider.
Any help you can give on coding this correctly would be very much appreciated.
Thank you. I've provided the main part of the note below
Indication for Surgery
23yr old G3P2012 s/p medical abortion with ongoing pain and concern for retained products of conception who presented for DandC.
Preoperative Diagnosis
Failed medical abortion
Pelvic pain
Postoperative Diagnosis
Same
Operation
Suction dilation and curettage
Surgeon(s)
Removed surgeon's name
Assistant(s)
none
Anesthesia
General_2
removed name (Anesthesiologist)
removed name (Anesthesia Care Provider)
Estimated Blood Loss
50ml
Urine Output
0ml
Findings
1. 8wk anteverted uterus
2. Possible retained products of conception vs organized clot
Infection Present at Time of Surgery
None
Specimen(s)
Specimen ID: A. Products of conception [1]
Specimen Type: Permanent [1]
Specimen Coll. Date: 02/10/2023 17:23:00 [1]
Specimen Source: Other/See comment [1]
Body Site: Site Unspec [1]
Implants
None
Complications
None
Drains
None
Technique
After informed and signed consent, the patient was taken to the operating room, where a huddle was performed with all appropriate surgical staff. General anesthetic was administered without difficulty. She was placed in high lithotomy position and prepped and draped in the usual sterile fashion. A pelvic examination revealed the findings above.
A bivalve speculum was placed into the vagina. A single tooth tenaculum was used to grasp the anterior lip of the cervix. Paracervical block was performed with 10ml of 0.5% Marcaine with epinephrine at 5 and 8 o'clock in the cervicovaginal junction. The cervix was dilated to 24 French with Pratt dilators. An 8mm rigid curved cannula was used to evacuate the uterine contents until a gritty texture was noted throughout.
The tenaculum was removed and the cervix was noted to be hemostatic. The speculum was removed concluding the procedure. All counts were correct. She was taken out of lithotomy position and awoken without difficulty. She was transferred to a gurney and taken to the recovery room awake, comfortable and stable.
I have a patient who had a failed medical abortion (other provider) and so she came to us with abdominal pain. We found retained products of conception ... I am at a loss on how to code this. We don't do abortions where I work, we deal only with SAB, IUFD, MAB, etc. I used 59812 for treatment of incomplete abortion ... and with POC still there that was the only CPT that fit. The diagnosis I used O07.4 Failed attempted termination of pregnancy without complication, although I didn't like it. Anyway, it was denied, not unexpectedly. There just don't seem to be any really decent diagnoses that would go with what this scenario is. We're being told to bill the State (Oregon) for the abortion but the codes are for induced abortions ... we're just dealing the POC that were not adequately removed by the other provider.
Any help you can give on coding this correctly would be very much appreciated.
Thank you. I've provided the main part of the note below
Indication for Surgery
23yr old G3P2012 s/p medical abortion with ongoing pain and concern for retained products of conception who presented for DandC.
Preoperative Diagnosis
Failed medical abortion
Pelvic pain
Postoperative Diagnosis
Same
Operation
Suction dilation and curettage
Surgeon(s)
Removed surgeon's name
Assistant(s)
none
Anesthesia
General_2
removed name (Anesthesiologist)
removed name (Anesthesia Care Provider)
Estimated Blood Loss
50ml
Urine Output
0ml
Findings
1. 8wk anteverted uterus
2. Possible retained products of conception vs organized clot
Infection Present at Time of Surgery
None
Specimen(s)
Specimen ID: A. Products of conception [1]
Specimen Type: Permanent [1]
Specimen Coll. Date: 02/10/2023 17:23:00 [1]
Specimen Source: Other/See comment [1]
Body Site: Site Unspec [1]
Implants
None
Complications
None
Drains
None
Technique
After informed and signed consent, the patient was taken to the operating room, where a huddle was performed with all appropriate surgical staff. General anesthetic was administered without difficulty. She was placed in high lithotomy position and prepped and draped in the usual sterile fashion. A pelvic examination revealed the findings above.
A bivalve speculum was placed into the vagina. A single tooth tenaculum was used to grasp the anterior lip of the cervix. Paracervical block was performed with 10ml of 0.5% Marcaine with epinephrine at 5 and 8 o'clock in the cervicovaginal junction. The cervix was dilated to 24 French with Pratt dilators. An 8mm rigid curved cannula was used to evacuate the uterine contents until a gritty texture was noted throughout.
The tenaculum was removed and the cervix was noted to be hemostatic. The speculum was removed concluding the procedure. All counts were correct. She was taken out of lithotomy position and awoken without difficulty. She was transferred to a gurney and taken to the recovery room awake, comfortable and stable.