Coding for the Treatment of “Abortions”

Pregnancy chapter codes are very complicated to use in coding. If you are medical coder, you would surely understand how difficult it is to find a correct ICD or CPT code in pregnancy chapter. I have made very big errors in past in ICD and CPT code while coding pregnancy medical reports. The major topic in this chapter is to discuss about coding ABORTION. I have learnt coding Z codes, pregnancy complication codes, Injury encounter codes but still I am struggling to code the Abortion ICD and CPT codes. Today, I would just share few tips for coding abortion procedures. 

The definition of “abortion” is the premature expulsion from the uterus of the products of conception, the embryo or a non-viable fetus. However, for the lay person, the coding or labeling of the medical record or report as “spontaneous abortion” may be somewhat problematic. The CPT codes properly use the medical term abortion. If you are want to be perfect in surgery coding, you have to understand every term related to abortion.

On the basis of the cause, abortions may be categorized as either spontaneous and induced. Spontaneous abortion, also known as Miscarriage and Pregnancy loss, is the natural death of an embryo or fetus before it is able to survive independently. Some use the cutoff of 20 weeks of gestation, after which fetal death is known as a stillbirth. Induced abortion is the intentional termination of a pregnancy before the fetus can live independently.

Different medical terms for Abortion

Abortion, threatened

Abortion, spontaneous

Abortion, incomplete

Abortion, missed

Abortion, septic

Ovum, blighted

Abortion, induced

Threatened Abortion

A threatened abortion is diagnosed when vaginal bleeding occurs in the first 20 weeks of pregnancy. The differential diagnosis of this bleeding that occurs in early pregnancy in approximately 20% of all patients is usually included in the antepartum care component of “routine” obstetric care of the patient who successfully delivers.

In the event that the patient being treated for a threatened abortion requires additional visits, these should be coded separately using evaluation and management services codes, according to the services the physician provides.

Read also: Coding tips for Maternity Care and Delivery Procedure codes

Coding for Spontaneous Abortion (Miscarriage)

Complete Abortion: All of the products (tissue) of conception leave the body.

When a spontaneous abortion, that is complete (any trimester),  of the products (tissue) of conception leave the body. occurs and the physician manages the patient medically, with no surgical intervention, the physician should assign the appropriate level of evaluation and management code, dependent on the place where the patient is seen (99202-99233).

Incomplete Abortion : Only some of the products of conception leave the body

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, protrude from the external os of the cervix, or can be found in the vagina. Some fragments of the products of conception may have spontaneously passed out of the vagina. Code 59812 is used to report the dilation and curettage (either sharp or suction curettage) for the surgical management of an incomplete abortion. However, if the patient is septic and is diagnosed as experiencing an incomplete abortion, do not use code 59812.

59812 – Treatment of incomplete abortion, any trimester, completed surgically

Relation Abortion CPT codes

59820 Treatment of missed abortion, completed surgically; first trimester
59821 second trimester
59830 Treatment of septic abortion, completed surgically
59840 Induced abortion, by dilation and curettage
59841 Induced abortion, by dilation and evacuation
59850 Induced abortion, by 1 or more intra-amniotic injections (amniocentesis-injections), including hospital admission and visits, delivery of fetus and secundines;
59851 with dilation and curettage and/or evacuation
59852 with hysterotomy (failed intra-amniotic injection)

Read also: When to use Hospice Modifiers GV and GW 

Blighted Ovum

The advent of diagnostic tools that aid in the very early detection of pregnancy such as beta subunit HCG and ultrasound, have clouded the clinical coding picture as to when early “abortion” occurs. In the instance of a positive pregnancy test, with a blighted ovum identified on ultrasound (a pathologic ova in which the embryo was degenerated or absent) raises the question of whether a code for treatment of abortion should be selected or a code for dilation and curettage, since there was not any (viable) product of conception present.

In many of these cases, women who did not seek medical attention for early diagnosis of pregnancy would not have previously identified a delayed menstrual cycle as the loss of a pregnancy nor have been aware that any conception had occurred. However, if a pregnancy is diagnosed and terminates, either by spontaneous or induced means, the abortion codes should be used to report the physician services related to the abortion.