CPT Assistant, Fall 1993, Volume 03, Issue 3, pages 9-10
Coding for the Treatment of "Abortions"
The definition of "abortion" is the premature expulsion from the uterus of the products of conception, the embryo or a non-viable fetus. However, for the lay person, the coding or labeling of the medical record or report as "spontaneous abortion" may be somewhat problematic. The CPT codes properly use the medical term abortion.
On the basis of the cause, abortions may be categorized as either spontaneous, the natural (with no active interference) termination of pregnancy prior to the 20th week of gestation, or induced, in which a deliberate attempt has been made to terminate the pregnancy.
A threatened abortion is diagnosed when vaginal bleeding occurs in the first 20 weeks of pregnancy. The differential diagnosis of this bleeding that occurs in early pregnancy in approximately 20% of all patients is usually included in the antepartum care component of "routine" obstetric care of the patient who successfully delivers. In the event that the patient being treated for a threatened abortion requires additional visits, these should be coded separately using evaluation and management services codes, according to the services the physician provides.
Spontaneous Abortion (Miscarriage)
When a spontaneous abortion that is complete (any trimester) occurs and the physician manages the patient medically, with no surgical intervention, the physician should report the appropriate level of evaluation and management code, dependent on the place where the patient is seen (99201-99233).
An incomplete abortion occurs when the uterus is not entirely emptied of its contents. Fragments of the products of conception may remain within the uterus, protrude from the external os of the cervix, or can be found in the vagina. Some fragments of the products of conception may have spontaneously passed out of the vagina. Code 59812 is used to report the dilation and curettage (either sharp or suction curettage) for the surgical management of an incomplete abortion. However, if the patient is septic and is diagnosed as experiencing an incomplete abortion, do not use code 59812. (See septic abortion.)
59812Treatment of incomplete abortion, any trimester, completed surgically
A missed abortion refers to the prolonged retention of a fetus that died in the first half of pregnancy. The evacuation of the uterus in these cases is coded according to the trimester in which the procedure is performed (ie, 59820 for the first trimester and 59821 for the second trimester).
59820Treatment of missed abortion, completed surgically; first trimester
hope this helps.
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