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Posted By Maria on 11-03-2020, 08:22:02 in Ob-Gyn
 Hello Melanie,

Thanks so much for your help on this one.

I want to use 59855 for this procedure, but there were no vaginal suppositories used, only oral dosing mispo. I read all documentation and she only would allow oral meds.

What would you recommend for the CPT code 59409? 59855-52

27 weeks with no heartbeat.

"I have seen the patient with the house officer. I have reviewed the findings, impressions and plans below and I agree. Ms. XXXis a 38 year old G3P1011 at 27w2d with hydropic appearing IUFD. Stillbirth evaluation was discussed with the patient and her partner.

"Plan: continue Q4 miso, advised vaginal dosing however she prefers oral dosing
-discussed pain control options (push meds, PCA, and epidural), she does not want anything right now but says that she will let us know if this changes"

"Induction: Cervical Ripening
Induction Indication: Fetal Demise
Cervical ripening: Misoprostol"

"Arrived into room following call from RN of patient urge to push. Upon arrival, noted to see delivered fetus on bed. Delivered fetus cord cut separated from placenta with clamp, hemostats and mayo scissors. Placenta was delivered with maternal efforts following fetal delivery. Examination of maternal perineum and genitalia revealed no perineal or genital lacerations. Fetus taken to warmer. Upon examination of fetus, fetal head appeared edematous. No gross abnormalities of fetus was appreciated. No appreciation of cleft lip, eye lid abnormalities, nasal bridge was appreciated. Bilateral upper and lower extremities were without abnormalities with 5 digits on each hand/extremity. Examination of back revealed no signs of neural tube defect, patent anus. Total EBL of delivery was 172cc. Maternal fundus was firm following delivery without further bleeding on palpation.
Dr. XXXX PTLA was present for the examination of the fetus, separation of fetus from placenta, delivery of placenta and maternal examination postpartum."
Comments (1)
Posted By Melanie Witt on 11-06-2020, 13:01:11
Since this was oral, you cannot bill anything but an E/M service, but in this case, she is being admitted for delivery at 27 weeks and the abortion codes would not be reported and the admit E/M service is always included. Just bill the delivery code that applies in this case (that is, did you provide all of the care or was the patient only seen this one time by the provider who has not provided any antepartum care). The diagnosis will be O36.4XX0, Maternal care for intrauterine death, not applicable or unspecified
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