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Posted By Glory P on 12-18-2018, 13:48:34 in Ob-Gyn
Please help with coding on this one.
G6P2214 with IUP @ 18w0d, Pregnancy complications - Previable pprom, after discussion of options she elected for induction for termination due to previable pprom R/B/A discussed. Labor - Induced with cytotec. Analgesia - IV Pain Meds, Fetal Heart Tones - none, labor interventions - none, Fetus: Male born with no heart beat 0830, appropriate size for gestation, normal appearing anatomy, no defects apparent. Placenta - delivered, spontaneously at 0830., intact with 3V Code. Lacerations - none, Complications - none. EBL 0 cc.

What CPT and ICD 10 would be most appropriate? 59856 OR 59821? O02.98? Z3A.18
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Posted By Melanie Witt on 12-25-2018, 14:32:14
As there was no D&C performed and it was induced, the code 59855 can be reported, but keep in mind that your payer may decide that this is an induced abortion and refuse payment, but this patient already had ruptured membranes. In that case, you can alternatively bill 59200 plus E/M services only for the management of the delivery. 59821 is only used when the fetus is surgically removed which is not the case here. As to the Dx codes, this can be classified as a spontaneous incomplete abortion (O03.4, Incomplete spontaneous abortion without complication), but you will not use a Z3A code. The ICD10 guidelines specifically state: Category Z3A codes should not be assigned for pregnancies with abortive outcomes (categories O00-O08), elective termination of pregnancy (code Z33.2), nor for postpartum conditions, as category Z3A is not applicable to these conditions.
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