The premature expulsion of the products of conception from the uterus is known as Abortion. It can be embryo or a non-viable fetus. In simple words, the coding or labeling of the medical report named as spontaneous abortion may be somewhat problematic. The CPT codes properly use the medical term abortion.
For abortion, another term “interrupted pregnancy” is often used. It refers to a pregnancy that did not proceed to full term. A full-term pregnancy is normally between 38 and 42 weeks of gestation. There are numerous ways to classify an interrupted pregnancy. It can be an abortion or it can be a miscarriage. Abortion or miscarriage both are considered as natural death of an embryo or fetus. A miscarriage is one of the most common complications of early pregnancy. Most commonly, a miscarriage happens within the first trimester of pregnancy. Generally coding for these types of complications can be difficult, as they don’t come under “normal pregnancy package “of antepartum care, delivery, and postpartum care.
There is a slight difference in timeframe definition of the term abortion versus fetal death, when we talk about the transition from ICD-9-CM to CD-10-CM. In ICD-9-CM, the definition of abortion codes is 22 weeks. In ICD-10-CM, the timeframe is changed to 20 weeks. The clinical documentation for the notation of trimester, or the notation of gestational weeks, in ICD-10-CM is imperative i.e. First trimester is 0-14 weeks, second trimester is 14-28 weeks, third trimester is 28-40 weeks.
Abortion CPT Codes: Elective, Missed, Spontaneous, Incomplete
Abortions may be categorized as either spontaneous, the natural termination of pregnancy prior to the 20th week of gestation, or a deliberate attempt has been made to terminate the pregnancy. There can be different causes of abortion, some of them are listed below:
A missed abortion refers to the prolonged retention of a fetus that died in the first half of pregnancy. In other words, an empty gestational sac, blighted ovum or a fetus or fetal pole with a heartbeat prior to completion of 20 weeks 0 days gestation, is termed as missed abortion.
The provider documents that a fetal death has occurred prior to the completion of 22 weeks gestation (in ICD-9-CM) or 20 weeks gestation (in ICD-10-CM) with the dead fetus remaining in the uterus for a period of time. According to ICD-9-CM definition, the timeframe used for missed abortion is 22 weeks while ACOG defines as 20 weeks. Beyond this period of time, code 656.43 is used for missed delivery, with diagnosis code: 632.
Missed abortion code is reported with only 3 digits. The evacuation of the uterus in cases like Sounding of uterus for size, serial dilation of cervix with mechanical dilators, emptying uterine cavity of products of conception using, administration of intravenous oxytocin, removal of instruments or repair of cervical incision. All these steps are coded according to the trimester in which the procedure is performed i.e.
- 59820 for the first trimester while completed surgically.
- 59821 for the second trimester while completed surgically.
Spontaneous Abortion (Miscarriage)
A spontaneous abortion that is complete (any trimester) and the physician manages the patient medically, without any surgical intervention is termed as complete abortion. In other words, if POC are expelled without surgical or medical intervention. It is also called miscarriage. It can be further categorized as septic or non septic. When the tissue from a missed or incomplete miscarriage becomes infected, it is called septic miscarriage. The infection of the uterus carries risk of spreading infection (septicemia) and is a grave risk to the life of the woman.
Diagnosis code for this case is 634 but procedure reported (depends on gestational age)with diagnosis code 634.X2. In such case, the physician should report the appropriate level of evaluation and management code, dependent on the place where the patient is seen. Code 99201 to 99233 are appropriate for such cases.
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, or can be found in the vagina. Some fragments of the products of conception may have spontaneously passed out of the vagina. A condition like this is called incomplete abortion.
The provider documents the POC "have not been expelled" or "incompletely expelled" from the uterus. Code 59812 is used to report the dilation and curettage for the surgical management of an incomplete abortion. Code 59812 is not appropriate, if the patient is septic and is diagnosed as experiencing an incomplete abortion.
Codes for different types of Abortions
Being a coder, your main task is to match up what is on the operative note to the CPT code for the most closely aligned services that are performed. Below is the entire listing of CPT services for abortive procedure services:
- 59812, treatment of incomplete abortion, any trimester, completed surgically.
- 59820, treatment of missed abortion; completed surgically, first trimester.
- 59821, treatment of missed abortion; completed surgically, second trimester.
- 59830, surgical treatment of septic abortion, completed surgically.
- 59840, induced abortion by dilation and curettage.
- 59841, induced abortion by dilation and evacuation.
- 59850, induced abortion by one or more intra-amniotic injections (amniocentesis injections), including hospital admission and visits, and delivery of fetus and secundines.
- 59851, induced abortion by one or more intra-amniotic injections (amniocentesis injections), including hospital admission and visits, and delivery of fetus and secundines; with dilation and curettage and/or evacuation.
- 59852, induced abortion by one or more intra-amniotic injections (amniocentesis injections), including hospital admission and visits, and delivery of fetus and secundines; with hysterotomy.
- 59855, induced abortion one or more vaginal suppositories (e.g., prostaglandin) with or without cervical dilation (e.g., laminaria), including hospital admission and visits, delivery of fetus and secundines.
- 59856, induced abortion one or more vaginal suppositories (e.g., prostaglandin) with or without cervical dilation (e.g., laminaria), including hospital admission and visits, delivery of fetus and secundines; with intra-amniotic injections, dilation and curettage and/or evacuation.
- 59857, induced abortion one or more vaginal suppositories (e.g., prostaglandin) with or without cervical dilation (e.g., laminaria), including hospital admission and visits, delivery of fetus and secundines; with vaginal suppositories and hysterotomy.