This recommendation would come directly from the ACOG Coding Committee made up of ob/gyn physicians, not a coder (having worked at ACOG for 12 years as the manager of their coding department). The rationale would be (and has always been) based on the work involved. These are set as possible coding option/scenarios for a medical abortion. If the physician adequately describes work involved in delivering the placenta, then by all means code for it. If the placenta simply is expelled by the patient with a push, not physician work would be reportable. Documentation makes or breaks the possibility of payment.
First thank you for explaining above. I have something like but little more complicated case that I'm stuck on and need help.
Our patient at 19 weeks pregnant, known fetal demise for several days. Came into the ED by ambulance with bleeding. The ED provider delivered the fetus and clamped the cord. Our provider was enroute to ED. Upon arrive in the ED transported the patient to L&D for further care of the Placenta left insitu. Also, with known retained IUD.
The provider did H&P 1/6 in plan stated the following:
PLAN/NEW ORDERS
Incomplete AB on admission
Fetus delivered without issue or complication in ED.
Placenta insitu administered 800mcg misoprostol vaginally.
Given concern for infection given foul odor triple antibiotics initiated.
Labs collected.
Ultrasound ordered.
Continue active management for placenta delivery.
Continue to monitor for change in condition.
The placenta was delivered on 1/6/ vaginally. After the delivery no IUD noted during the delivery. Ultrasound and X-ray was ordered. No IUD was seen on the on ultrasound, however on the Xray IUD was seen and STAT CT ordered for localization of IUD.
CT scan reviewed. IUD has perforated the uterus and is in the abdomen. Patient has been counseled and consented to laparoscopic IUD retrieval and any other indicated procedure. Patient is aware of the potential for more invasive surgery if the IUD has perforated/damaged surrounding organs or structures. Is aware of the potential surgical risks that include but are not limited to infection, bleeding, damage to internal organs and structures. patient is aware of the potential for hysterectomy, bowel resection, or larger abdominal incision. Patient is aware that we are unaware at this time to the extent which the IUD has damaged internal organs and structures and we will be unable to determine the extent of surgery until the surgery has commenced. Demonstrates understanding. Given predelivery anemia patient will be transfused 2 units of packed red blood. She has been consented and has agreed to blood transfusion.
On 1/7 Laparoscopic removal of IUD was performed.
A general abdominal survey was noted to be normal.
Uterus was noted to be significantly enlarged and boggy likely secondary to recent delivery.
the uterus was difficult to manipulate secondary to its bogginess, size, and lack of uterine manipulator (secondary to recent delivery).
Although it was difficult to clearly visualize the posterior lower uterine segment there did appear to be a small area <2mm of perforation that was hemostatic. Due to the hemostatic nature this area was left alone for healing by secondary intention.
Attention was then paid to abdominal inspection for lost IUD. Bowel and omentum were manipulated using the suction irrigator and a bowel grasper gently sweeping and manipulating the bowel without direct grasping. During inspection a portion of the IUD string was visualized. The string was grasped, and it appeared that the IUD was present in an area of omentum. Using gentle traction and manipulation the IUD was removed from the omentum without evidence of bleeding or injury to omentum or bowel.
IUD was removed through the trocar without difficulty.
The abdomen was copiously irrigated and suctioned with a liter of fluid.
The omentum where IUD was removed appeared hemostatic.
Uterus and area of the lower uterine segment appeared hemostatic.
Instruments were removed.
1/8/24 Patient was discharged from the hospital by different provider of our practice.
With my understanding of your response, I could code this case as the following:
1/6 99222-25 along with 59414
1/7 Laparoscopy removal of IUD i would code 49329 Unlisted Laparoscopy procedure, abdomen, peritoneum and omentum. Would it be correct to compare to 58562.
1/8 My question for this date of service could I code for the discharge as well? 99238 since time was not documented?
). From what I have learned from this forum, if it was a surgical D&C, then 59821 but it was not. I think it was induced delivery by Cytotec, then there is a rule ( also posted in this fabulous OBGYN forum) if pt is 20w and up, then code the Delivery with demised fetus. IF less than 20w, code E&M only. There is another rule, if induced by Vaginal suppositories regardless of gestation, then 59855-59856. Now let's wait for the correct answer. 