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Help with abortion coding

  1. #1
    Default Help with abortion coding
    Medical Coding Books
    I am having trouble deciding if this would be 59821 or 59855? I really get stuck on these. She was given cytotec which is why I am leaning towards 59855?

    Can someone confirm this for me? Thanks!!!

    A 25-year-old black female, G (gravida) 2, P (para) 0,
    A (abortion) 1, LC (living children) 0, at approximately 16+ weeks
    intrauterine pregnancy, who had spontaneous rupture of membranes with
    dilated cervix. She was admitted with an inevitable spontaneous
    abortion. The patient had 800 mcg of Cytotec placed rectally and after several hours was feeling pressure.
    DELIVERY NOTE: The patient pushed secondary to feeling that she was
    having a bowel movement, but passed the fetus that was a 16 week size,
    nonviable, no heartbeat identified or fetal movement identified by
    nurse evaluation. The cord was clamped and cut. Bleeding minimal.
    Dr. R then arrived to assess the patient. She was stable and
    was comfortable. On exam the cervix was dilated and noted placental
    tissue partially extruding through the cervix. It was decided to be
    conservative and wait for spontaneous passage, fundal massage used.
    After an hour or so, the patient passed a large portion of placental
    tissue. Bleeding controlled. It was decided again to wait further for
    the rest of the placental tissue. Risks, benefits, and indications
    reviewed with the patient, regarding this conservative treatment for
    the passage of the placenta. Patient in agreement. She understands
    that she may need a dilation suction curettage if she does not pass the
    rest of the tissue by tomorrow morning.
    Rhonda Green, CPC

  2. #2
    <20 WEEKS delivery and since cytotec was used the 59855 is the correct code. i have some information on this so you can fight insurance and/or have the info available if you want it. just email me and i can give you what i have on it.

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