Superb Coding guide on Induced Abortion for Coders

Basics about Induced Abortion

We have learnt already about the spontaneous abortion, now we will learn about induced abortion. Therapeutic and elective abortions may be classified as induced abortions. Therapeutic abortion is the termination of pregnancy before the time of fetal viability for medical indications. Elective abortion is the interruption of pregnancy before viability at the request of the woman.

Induced abortion coding depends on the technique used. Since, it is an intentional termination of pregnancy, certain injection of drugs are given to the patient to prevent the fetus from further developing. The Procedure codes for induced abortion are reported on the basis of the technique used. This may be done surgically, by dilating the cervix and performing curettage or using vacuum aspiration.

Medical induction may be performed by the administration of oxytocin or the administration of prostaglandins. Intraamniotic injections of saline or urea are also used to induce abortions.

CPT codes used for Induced aboriton

When an induced abortion is performed by dilating the cervix and performing sharp and/or suction curettage, use CPT code 59840 for reported such procedures.

59840 – Induced abortion, by dilation and curettage

If the cervix is dilated and the uterus mechanically evacuated, code 59841 is reported. In the event that a small amount of sharp curettage is needed to complete the dilation and evacuation, this is included when reporting 59841.

59841 – Induced abortion, by dilation and evacuation

Abortions performed during the second trimester are sometimes performed using intra-amniotic hyperosmotic solutions (saline or urea). These solutions are injected to stimulate uterine contractions and cervical dilation to deliver the products of conception. This is coded using 59850, and includes admission to a facility, necessary hospital visits and follow-up care.

59851 Induced abortion, by one 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 intraamniotic injection)

In the event that the intra-amniotic injections facilitate the evacuation of the uterus, but curettage and/or dilation is necessary to complete the procedure, code 59851 is reported.

If other methods are not successful or if there are additional indications, an abdominal hysterotomy may be necessary to terminate pregnancy. This technique is similar to the technique of cesarean delivery, except that the abdomen and uterus are generally smaller. In this case, code 59852 is reported and encompasses both the attempted intra-amniotic injections as well as the surgical hysterotomy.

If a laminaria is inserted prior to any of the procedures discussed in this article, code 59200 may also be reported, as it is not included as a part of any of the other procedures.

59200 – Insertion of cervical dilator (eg, laminaria, prostaglandin)(separate procedure)