Wiki CPT 59830 VS 59840

[rockylopez]

Hello Coders. I have an op report for blighted ovum/septic AB and i am gearing towards cpt 59830 but then again I think due to blighted ovum and light vaginal bleeding op report seems like it was more of an induced AB (59840) any input is appreciated.

Pre-procedure diagnosis:
Blighted ovum, suspect septic AB
Post-procedure diagnosis:
Same
Procedures performed:
Suction D&C, ultrasound confirmed
Technique/Procedure:
Suction D&C
Operative findings:
Mild vaginal bleeding. Cervix dilated well, easily to 12 mm. Using 8mm flexible curettee, suction
performed, products noted. Confirmed w u/s all tissue was removed.
Complications: none
Estimated blood loss in ml's: minimal
Specimens removed/altered: Products of conception
Cultures sent: Yes
Implant(s): none
Approach: vaginally

 

[Cmama12]

Hi, since bleeding is mentioned, I would use 59812. (59820 if not). I would not use septic abortion since the note states "suspected." The induced abortion codes are for when the mother chooses to terminate the pregnancy, elective or indicated. In this case, nature is terminating the pregnancy, so it is not induced.

 

[rockylopez]

Hi, since bleeding is mentioned, I would use 59812. (59820 if not). I would not use septic abortion since the note states "suspected." The induced abortion codes are for when the mother chooses to terminate the pregnancy, elective or indicated. In this case, nature is terminating the pregnancy, so it is not induced.

thank you so much for your response. The only reason why i was gearing towards 59830 is because on the post op note the following day the provider confirmed on the note that the purpose of the procedure was due to septic ab.

Discharge diagnosis:
POD #1 status post suction curettage, septic abortion
Hospital course:
Patient was admitted with septic abortion. She was started on IV antibiotics and was subsequently taken to the operating room where she underwent a suction curettage image guided. It was uncomplicated.

 

[Cmama12]

thank you so much for your response. The only reason why i was gearing towards 59830 is because on the post op note the following day the provider confirmed on the note that the purpose of the procedure was due to septic ab.

Discharge diagnosis:
POD #1 status post suction curettage, septic abortion
Hospital course:
Patient was admitted with septic abortion. She was started on IV antibiotics and was subsequently taken to the operating room where she underwent a suction curettage image guided. It was uncomplicated.

We can only pull dx from the op note itself. If you are able to query your provider and get them to specifiy it in the note, then I would agree. Also, based on what was in the post op note, I would ask for clearer documentation of u/s use.. the way it's currently written makes it sound as if it was done pre or post, not during. If it was during, you could add 76998-26 for the u/s guidance.