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Manual Extraction of placenta, D&C, Ultra-Sound Guidance

  1. #1
    Question Manual Extraction of placenta, D&C, Ultra-Sound Guidance
    Medical Coding Books
    Hello all

    I am fairly new in the OBGYN field and am looking for assistance coding this delivery where the patient returned to the OR due to retained placenta. I am coding the professional component for the OBGYN.

    The op note states:

    Findings: Retained placenta was about a 2-cm area of the placenta attached at the anterior fundus. With manual once the placenta was removed, there was still placenta at the fundus of the uterus, and then using the ultrasound guidance, sharp curettage was performed to remove the retained products of conception.

    Description of Procedure:
    The patient was taken to the operating room where her epidural was found to be adequate with lidocaine that was given by the anesthesiologist. She was placed in Allen stirrups, prepped and draped in the usual sterile fashion. She did receive 2 grams of Ancef. At this time manual extraction was performed of the placenta; however, it was not intact. At the top of the fundus of the uterus there was still about a 2cm area of the placenta that was palpated. I reached in there with my hand and was able to retrieve a little bit more of the placenta, but there were some clear attachments to the uterus of some calcified placenta. An ultrasound was then performed, and it confirmed that there were still products of conception at the fundus of the uterus. Therefore, under ultrasound guidance the anterior lip of the cervix was grasped with ring forceps, and then sharp curettage was performed, retrieving these products of conception. The patient tolerated the procedure well. An ultrasound was again performed and revealed a clear endometrial stripe. Therefore, the instruments were removed from the pelvis, the ring forceps and the weighted speculum. The patient was taken out of Allen stirrups. She was taken to the recovery room in labor and delivery. The Foley remained in place. She will be there for the next 2-4 hours to observe her bleeding.

    Any help on proper coding for this procedure would be appreciated.

    Thanks!

  2. #2
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    Tacoma, WA
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    Quote Originally Posted by NVobgynCoder View Post
    Hello all

    I am fairly new in the OBGYN field and am looking for assistance coding this delivery where the patient returned to the OR due to retained placenta. I am coding the professional component for the OBGYN.

    The op note states:

    Findings: Retained placenta was about a 2-cm area of the placenta attached at the anterior fundus. With manual once the placenta was removed, there was still placenta at the fundus of the uterus, and then using the ultrasound guidance, sharp curettage was performed to remove the retained products of conception.

    Description of Procedure:
    The patient was taken to the operating room where her epidural was found to be adequate with lidocaine that was given by the anesthesiologist. She was placed in Allen stirrups, prepped and draped in the usual sterile fashion. She did receive 2 grams of Ancef. At this time manual extraction was performed of the placenta; however, it was not intact. At the top of the fundus of the uterus there was still about a 2cm area of the placenta that was palpated. I reached in there with my hand and was able to retrieve a little bit more of the placenta, but there were some clear attachments to the uterus of some calcified placenta. An ultrasound was then performed, and it confirmed that there were still products of conception at the fundus of the uterus. Therefore, under ultrasound guidance the anterior lip of the cervix was grasped with ring forceps, and then sharp curettage was performed, retrieving these products of conception. The patient tolerated the procedure well. An ultrasound was again performed and revealed a clear endometrial stripe. Therefore, the instruments were removed from the pelvis, the ring forceps and the weighted speculum. The patient was taken out of Allen stirrups. She was taken to the recovery room in labor and delivery. The Foley remained in place. She will be there for the next 2-4 hours to observe her bleeding.

    Any help on proper coding for this procedure would be appreciated.

    Thanks!
    Because the procedure was completed as a D&C that is what you will code. 59160 with dx code 667.xx (whichever dx code is appropriate).
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

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