Technological advances enable physicians to detect pregnancy in its earliest stages but make coding for spontaneous or missed abortions more complicated. When a patient presents with no prior pregnancy diagnosis, tools such as ultrasound and beta subunit HCG (human chorionic gonadotropin, a pregnancy test that helps determine the stage of pregnancy) confirm pregnancy and enable physicians to determine how far it has progressed. When a patient presents with a pregnancy that has already terminated through nonelective abortion, coding for diagnosis and procedural care can be a challenge, especially for very early-term pregnancies. Often, women who did not seek medical attention for early diagnosis of pregnancy will not identify a delayed menstrual cycle as the loss of a pregnancy and will not be aware that conception occurred. If a pregnancy is diagnosed and terminates, either by spontaneous or induced means, the abortion codes should be used to report the related physician services.
Abortion Terminology
Familiarization with the common types of abortions is the first step to assigning the right ICD-9 and CPT codes.
Complete: The complete expulsion or extraction from its mother of a fetus or embryo; complete expulsion from the uterus of any other product of conception.
Elective: Without medical justification but done in a legal way.
Incomplete: Part of the products of conception have been passed but part (usually the placenta) remains in the uterus.
Induced: Expulsion of the fetus and products of conception brought on purposefully by drugs or mechanical means.
Inevitable: Characterized by rupture of the membranes in the presence of cervical dilation in a pre-viable pregnancy.
Missed: Death of the fetus in utero prior to 22 weeks, with retention of the products of conception.
Septic: An infectious abortion complicated by fever, endometriosis or parametritis.
Spontaneous: An abortion that has not been induced artificially. The term is usually limited to pregnancies of less than 22 weeks gestation.
Editors note: CPT codes for induced abortion (59840-59857) do not distinguish between elective (not medically necessary) or nonelective (medically necessary) abortions. ICD-9 codes 634.x-637.9 describe spontaneous (nonelective) (the fourth digit indicates the contributing complication), legally induced (elective), illegally induced (elective) and unspecified abortion (nonelective).
Spontaneous vs. Missed Abortion
Carla Bryan, CPC, practice manager at Womens Care, a two-physician, one-nurse midwife ob/gyn practice in Hartsville, S.C., says that when determining the right CPT code for a nonelective abortion, the first parameter is whether surgery was required to complete the process. If the patient presents with a spontaneous abortion that is complete (meaning there were no products of conception retained in the uterus), we treat the patient and code it as an evaluation and management (E/M) visit, with no other CPT code, since nothing else was done. Code 634.x (spontaneous abortion) is used for diagnosis. If Bryans physician must evacuate a dead fetus from the uterus through a dilation and curettage (D&C), 632 (missed abortion) is used for the diagnosis, and 59820 (treatment of missed abortion, completed surgically; first trimester) or 59821 (treatment of missed abortion, completed surgically; second trimester) is used for the D&C. By using the code for missed abortion, you indicate that there are retained products of conception that must be surgically removed. A spontaneous abortion code implies that there are no retained products in the uterus and, therefore, no procedural code, she says.
If Its Not Technically a Pregnancy
What procedural codes apply when the patient enters the exam room unaware that she is pregnant, and the diagnosis is something other than a missed abortion? One example is when a physician performs a D&C for a blighted ovum (631, other abnormal product of conception). The code for dilation and curettage, nonobstetrical (58120) doesnt appear to be the answer, but the correct code depends on when or if the blighted ovum and pregnancy were discovered.
The treatment for a blighted ovum, which is a fertilized egg that fails to develop a fetus within it, may be the same as a missed abortion, but only if a pregnancy has been confirmed. Melanie Witt, RN, CPC, MA, former program manager for the American College of Obstetricians and Gynecologists (ACOG) department of coding and nomenclature and an independent coding educator, explains the distinctions. A blighted ovum may reabsorb before it is detected, or the patient may exhibit signs of miscarriage. The patient may come in with unexplained vaginal bleeding before she realizes that she may have been pregnant, and a pregnancy test comes back negative. If this is the case, Witt explains, and there is a negative pregnancy test, the proper code for the D&C is 58120 (dilation and curettage, diagnostic and/or therapeutic [nonobstetrical]) even if the pathology report indicates a blighted ovum after the fact.
On the other hand, if the patient has been diagnosed as pregnant either prior to or at the same visit, and then begins bleeding, the patient may spontaneously abort (E/M code only) or may require surgery to remove the contents. The blighted ovum may not show up until the pathological reports come back, but because there was a positive pregnancy test, 59812 is used to indicate treatment of incomplete abortion, any trimester, competed surgically.
Although unusual, a patient with a blighted ovum may complain of a missed period only. The physician is likely to order a pregnancy test and do an ultrasound. If the pregnancy test is positive, and the ultrasound reveals a blighted ovum (but no symptoms of abortion, i.e., discharge or vaginal bleeding), the physician will perform a D&C, and 59820 or 59821 would be used along with code 631.
With a blighted ovum, says Witt, you are not inducing abortion because there is no fetus; rather you may be helping along what nature has already started. She adds that, before tests revealed pregnancy at its earliest stages, physicians were more inclined to let nature takes its course and let the body either expel or reabsorb the blighted ovum. But D&Cs or other abortion methods are now employed much more frequently to treat incomplete abortions or induce abortions when a pregnancy is not viable.
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