Dilation and Evacuation for fetal death, 24 weeks

natashalage

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Hello coding community! We have a different opinion on how to code the case below: Cpt and Dx. We would like to hear your rational. Thank you very much for your help. :)
We both agree that with 76998 US and -22 for extra work, we disagree on Px and Dx.
Option 1: 59841-22 D&E, 76998 with dx O03.4-SAB 24 weeks
Option 2: 59821-22, 76998 with O36.4xx0 24 weeks, 59821- Treatment of missed abortion, completed surgically; second trimester

O03.4 Incomplete spontaneous abortion without complication
O36.4xx0- Maternal care for intrauterine death, not applicable or unspecified

PROCEDURE: Standard dilation and evacuation/D and E
CLINICAL INDICATIONS: . G2P0010 at 24+0d with fetal demise
She was seen yesterday on L&D where ..She had cervical preparation with Cervical osmotic dilators overnight ..
PROCEDURE: ... Dilation was assessed and found to be slightly inadequate. Dilation performed with Pratt dilators to 45 Fr. A 14 mm suction cannula was advanced and the amniotic fluid removed. Bierer forceps were used to transect the umbilical cord and to evacuate fragmented fetal parts and placenta. Sharp curettage was used to confirm an empty uterine cavity and suction aspiration was repeated. Throughout the procedure we were careful to pass the instruments carefully into the uterine cavity due to significant distortion from a posterior lower uterine segment fibroid.

Hemostasis was not satisfactory at the end of the procedure. Methergine and then TXA was given. An ultrasound revealed a thin uterine stripe. The posterior cervix was raw and did not become hemostatic after pressure and application of Monsel's solution. The cervix was whip-stitched from 6:00 to 9:00 with running locked 0-Vicryl. Additional Monsel's and pressure were applied and then hemostasis was satisfactory. All instruments were removed from the vagina and the patient was taken to the post-anesthesia recovery room awake and in stable condition. Products of conception were examined and noted to be complete.

INTRAOPERATIVE SONO: Indication for intraoperative sono: D&E performed with forceps.

SPECIMEN: products of conception were sent fresh, permanent to pathology. Small section of fetus and placenta were sent for microarray (SNP)
 

natashalage

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Thank you, Sharon! I am stuck on dx.

My gut tells me it’s a Missed abortion and that’s why I went to 59821 for second trimester. But what puzzled me is the Dx MD put- O36.4xx0-fetal demise not O02.1.

In “OB/GYN Comprehensive guide book 2020’ 59821 and 59841 both have dx for fetal death but in a different format. 59821 has only one Dx- Missed AB along with definition –retention dead fetus where fetal demise occurred before 20 w (ME: however, 59821 second trimester is up to 27 w) Our fetus is 24w.

59841 has listing O36.4xx0- intrauterine death and that’s what MD stated. There is no Missed AB for 59841. So, both CPT are for Fetal Death, they both have no Heart Beat. Our case could fall into both CPT since pt is 24w and Evacuation of the dead fetus was done.

We know that a natural abortion didn’t’ happen and now we will do elective, induced, surgical expulsion of the dead fetus. The question is which code to choose? If MD had put Missed abortion dx that would help the coder to go straight into 59821 but MD stated ‘fetal demise.” I am puzzled.

The Encoder has Excludes 1 under O36.4-
missed abortion (O02.1) (O02.1)
Should I assign Missed AB O02.1 and go with 59821?
 

SharonCollachi

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I never, ever, ever count on my MD to know what the nuances of coding diagnoses are. To him, missed abortion and fetal demise would be the same thing. Heck, mine makes up stuff all the time. He will say "lower back pain, severe" and when I try to tell him there is no "severe" (or other intensity), he says, of course there is. I say: not in the Land of 10, there isn't. (Land of ICD10)
 

Cmama12

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Thank you, Sharon! I am stuck on dx.

My gut tells me it’s a Missed abortion and that’s why I went to 59821 for second trimester. But what puzzled me is the Dx MD put- O36.4xx0-fetal demise not O02.1.

In “OB/GYN Comprehensive guide book 2020’ 59821 and 59841 both have dx for fetal death but in a different format. 59821 has only one Dx- Missed AB along with definition –retention dead fetus where fetal demise occurred before 20 w (ME: however, 59821 second trimester is up to 27 w) Our fetus is 24w.

59841 has listing O36.4xx0- intrauterine death and that’s what MD stated. There is no Missed AB for 59841. So, both CPT are for Fetal Death, they both have no Heart Beat. Our case could fall into both CPT since pt is 24w and Evacuation of the dead fetus was done.

We know that a natural abortion didn’t’ happen and now we will do elective, induced, surgical expulsion of the dead fetus. The question is which code to choose? If MD had put Missed abortion dx that would help the coder to go straight into 59821 but MD stated ‘fetal demise.” I am puzzled.

The Encoder has Excludes 1 under O36.4-
missed abortion (O02.1) (O02.1)
Should I assign Missed AB O02.1 and go with 59821?
I get what you're saying, and I'm not sure why 59841 has that dx and some others listed - as I've always been told to use the induced abortion codes when it's a termination. For the dx, being that it's the weeks of pregnancy that is the difference and specified in ICD 10 : Missed abortion up to 20 weeks and O36 .4 for after 20 weeks. I would use the O36.4 with 59821
 
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