Ob-Gyn Coding Alert

Question: A patient delivered a fetus and placenta intact at 17 weeks. The ob-gyn did not perform a dilation and curettage (D&C). The patient had no complaints, and so the ob-gyn sent her home on the same date. Should I just use a CPT code for an admit and discharge (9923x)?

South Carolina Subscriber

Answer: Yes, you are correct. You should bill for the admission and same-day discharge code (99234-99236,Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date -).

Reason: Because the encounter is medical management of a spontaneous abortion, CPT instructs you to bill the whole thing using E/M codes.