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incomplete abortion tx

  1. #1
    Grants Pass
    Default incomplete abortion tx
    Medical Coding Books
    Help with CPT please.
    Pt 9 weeks pregnant with fetal demise noted on ultrsound 2 weeks ago. Pt presented to office for f/u on incomplete abortion with mild bleeding. Pt had 2 doses of cytotec and had not passed tissue.
    In office, speculum exam done, cervical os was open with signs of tissue at cervical os. Vaginal bleeding was noted. Cervical tissue was grasped with ring forceps and was pulled out. Contined bleeding was noted. A tenaculum was placed in the cervix. Sharp curette was inserted into uterine cavity to approx 9 cm. Endometrial contents were completely removed using sharp curette and ring forceps. After curetting was done, uterus clamped down and there was no futher heavy bleeding.
    Surgeon indicated incomplete AB and retained products of conception. This is a new procedure for me to code and have not found a CPT that correctly describes the procedure done. Using an E&M code does not seem correct. Any help with this will be greatly appreciated.

  2. Default
    It was an induced abortion (with cytotecs- a medical induction) and the incompleteness will not be viewed as a different condition from/or than the induced status. It is by all means an induced abortion.
    I would like to suggest 59856 as the appropriate one for this situation.
    Thank you.
    Last edited by preserene; 03-10-2011 at 03:07 PM.

  3. Default
    Just curious...59856 includes hospital admission and visits. Karen stated services were provided in the office. Is it still ok to use 59856?

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