Rgreen0118
Guest
I am having trouble deciding if this would be 59821 or 59855? I really get stuck on these. She was given cytotec which is why I am leaning towards 59855?
Can someone confirm this for me? Thanks!!!
A 25-year-old black female, G (gravida) 2, P (para) 0,
A (abortion) 1, LC (living children) 0, at approximately 16+ weeks
intrauterine pregnancy, who had spontaneous rupture of membranes with
dilated cervix. She was admitted with an inevitable spontaneous
abortion. The patient had 800 mcg of Cytotec placed rectally and after several hours was feeling pressure.
DELIVERY NOTE: The patient pushed secondary to feeling that she was
having a bowel movement, but passed the fetus that was a 16 week size,
nonviable, no heartbeat identified or fetal movement identified by
nurse evaluation. The cord was clamped and cut. Bleeding minimal.
Dr. R then arrived to assess the patient. She was stable and
was comfortable. On exam the cervix was dilated and noted placental
tissue partially extruding through the cervix. It was decided to be
conservative and wait for spontaneous passage, fundal massage used.
After an hour or so, the patient passed a large portion of placental
tissue. Bleeding controlled. It was decided again to wait further for
the rest of the placental tissue. Risks, benefits, and indications
reviewed with the patient, regarding this conservative treatment for
the passage of the placenta. Patient in agreement. She understands
that she may need a dilation suction curettage if she does not pass the
rest of the tissue by tomorrow morning.
Can someone confirm this for me? Thanks!!!
A 25-year-old black female, G (gravida) 2, P (para) 0,
A (abortion) 1, LC (living children) 0, at approximately 16+ weeks
intrauterine pregnancy, who had spontaneous rupture of membranes with
dilated cervix. She was admitted with an inevitable spontaneous
abortion. The patient had 800 mcg of Cytotec placed rectally and after several hours was feeling pressure.
DELIVERY NOTE: The patient pushed secondary to feeling that she was
having a bowel movement, but passed the fetus that was a 16 week size,
nonviable, no heartbeat identified or fetal movement identified by
nurse evaluation. The cord was clamped and cut. Bleeding minimal.
Dr. R then arrived to assess the patient. She was stable and
was comfortable. On exam the cervix was dilated and noted placental
tissue partially extruding through the cervix. It was decided to be
conservative and wait for spontaneous passage, fundal massage used.
After an hour or so, the patient passed a large portion of placental
tissue. Bleeding controlled. It was decided again to wait further for
the rest of the placental tissue. Risks, benefits, and indications
reviewed with the patient, regarding this conservative treatment for
the passage of the placenta. Patient in agreement. She understands
that she may need a dilation suction curettage if she does not pass the
rest of the tissue by tomorrow morning.