Vol. 15 •Issue 2 • Page 10
Coding Corner
Coding Guidelines for Obstetrical Procedures
Case Study 1
Preoperative Diagnosis: Incomplete abortion
Postoperative Diagnosis: Incomplete abortion
Procedure: The patient was on the operating table, placed in the lithotomy position and administered 25 mg of Demerol IV. The vagina and cervix were visualized. The cervix was cleansed of blood with betadine swab and clasped with a single-tooth tenaculum. The paracervical and posterior cervical lip areas were injected with 12 cc of 1% xylocaine. The uterus sounded in the anterior position to 8 cm. The cervix was dilated to allow 8 mm suction tip. The suction tip was inserted in the anterior uterus. The contents of the uterine cavity were evacuated.
There appeared to be endometrial and placental tissue. There were some areas of dark clot associated with it. There was no evidence of fluid. The total quantity was approximately 10 cc. The suction was concluded. The uterine cavity was explored with stone forceps and appeared to be empty. The walls were curetted gently, without evidence of residual debris, and the procedure was concluded.
Pathology Report
Gross: Labeled products of conception are fragments of tan to red-tan soft friable tissue with a volume of approximately 3 ml. The specimen is totally submitted in two cassettes.
Microscopic: Fragments of decidua and gestational endometrium are identified. Chorionic villi and fetal tissue are not detected.
Diagnosis: Products of conception; fragments of decidua and gestational endome-trium, no chorionic villi or fetal tissue are identified.
ICD-9-CM Code Assignments
Preoperative: Incomplete abortion
637.91 Unspecified abortion without mention of complication
Postoperative: Incomplete abortion
637.91 Unspecified abortion without mention of complication
CPT Code Assignments and Rationale
The physician performed a dilation and evacuation (a surgical procedure) to treat an incomplete spontaneous abortion. Code 59812 describes this procedure and should be assigned for both the facility and professional codes.
To arrive at this code, check the CPT manual index under the term Abortion, then See Obstetrical Care. The term that follows, is Incomplete with the code of 59812.
Next look under the entry Obstetrical Care, which is immediately followed by the term Abortion, indented under this term is Spontaneous with the code 59812.
59812 Treatment of incomplete abortion, any trimester, completed surgically
Case Study 2
Preoperative Diagnosis: Premature rupture of membranes; intrauterine pregnancy at 35 weeks; footling breech
Postoperative Diagnosis: Premature rupture of membranes; intrauterine pregnancy at 35 weeks; footling breech
Procedure: Primary cesarean section, low cervical transverse type
Surgical Procedure: The patient was taken to the operating room and draped and prepped in the usual manner for an abdominal procedure. Once prepared for surgery, spinal anesthesia was administered.
A lower abdominal transverse incision was made with a knife, and the abdomen was entered in layers and without complications. The uterus was identified, the bladder flap was created, and the bladder retractor placed. A lower uterine segment transverse incision was made with a knife and extended with Mayo scissors.
A 5 pound, 14 ounce male infant was born in the footling breech presentation. The baby was suctioned immediately and taken to the physician in attendance for the baby.
The Apgars were 9 at 1 minute and 9 at 5 minutes. The placenta was manually removed and the uterus explored. The uterine incision was repaired with 0 Vicryl in a running fashion, and a second imbricating layer of 0 Vicryl was employed. At this point, the uterine incision was noted to be dry.
The tubes and ovaries were visualized and normal. The bladder peritoneum was closed with 2-0 Vicryl in a running fashion. The gutters were cleansed of any excess blood or fluid at this time. The peritoneum was closed with 0 Vicryl in a running fashion. The fascia was closed with 0 Vicryl in an interrupted figure of 8 fashion. The subcutaneous tissue was closed with a 3-0 Vicryl, and the skin approximated with a 3-0 Vicryl subcuticular suture.
The patient tolerated the procedure without complications. The sponge count was correct at the end of the case.
Addendum: There was a septum in the fundus of the uterus that may have explained the malpresentation. Two grams of Ancef were given after the cord was clamped.
NOTE: The physician provided all an-tepartum care and will provide all postpartum care.
ICD-9-CM Code Assignments
Preoperative: Premature rupture of membranes; intrauterine pregnancy at 35 weeks; footling breech
658.11 Premature rupture of membranes, delivered, with or without mention of antepartum condition
652.81 Other specified malposition or malpresentation, delivered, with or without mention of antepartum condition
644.21 Early onset of delivery, delivered, with or without mention of antepartum condition
Postoperative: Premature rupture of membranes; intrauterine pregnancy at 35 weeks; footling breech
658.11 Premature rupture of membranes, delivered, with or without mention of antepartum condition
652.81 Other specified malposition or malpresentation, delivered, with or without mention of antepartum condition
644.21 Early onset of delivery, delivered, with or without mention of antepartum condition
CPT Code Assignments
There is no mention that a vaginal delivery was attempted. The physician provided all obstetrical care; therefore, code 59510 is correct. It may be assigned for both the facility and professional services.
To arrive at this code, consult the CPT manual index for the term Cesarean Delivery. An entry under this term is Routine Care — 59510 — the correct code.
59510 Routine obstetric care including antepartum care, cesarean delivery and postpartum care
Sallie Williamson is a senior health care consultant with Medical Learning Inc. (Med-Learn®), St. Paul, MN.
