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Posted By Mary Peabody on 01-02-2020, 11:55:31 in Ob-Gyn
Hi Melanie,

If a D & E is performed on a fetal demise at 21 weeks, do we report procedure with CPT 59820-22 or with a delivery code 59409?

PREOP DIAGNOSIS: Intrauterine fetal demise at 21w2d
PROCEDURE: Standard dilation and evacuation/D and E
______a 28 y.o.  G2P0010 at 21w2d by L=9. She presents today after being diagnosed with an intrauterine fetal demise at her anatomy scan 
The patient was taken to the OR with IV running and anesthesia was administered. She was placed in the dorsal lithotomy position. An open-sided speculum was placed in the vagina and 6 cervical dilators and gauzes were removed. The cervix was cleaned with betadine. Cervical block with 10 mL of 1% lidocaine + 5 units vasopressin was administered and an atraumatic tenaculum was placed on the anterior lip of the cervix. Abdominal ultrasound was placed and continued throughout the procedure. Dilation was assessed and found to be inadequate dilation performed with Pratt dilators to 65. A 14 mm suction cannula was advanced and the amniotic fluid removed. Sopher then Bierer forceps were used to evacuate fragmented fetal parts and placenta. Sharp curettage was used to confirm an empty uterine cavity and suction aspiration was repeated. Good hemostasis was noted after the procedure.
All instruments were removed from the vagina and the patient was taken to the post-anesthesia recovery room awake and in stable condition. Products of conception were examined and noted to be complete.
INTRAOPERATIVE SONO: Indication for intraoperative sono: D&E performed with forceps. Realtime ultrasound guidance was performed transabdominallly during the procedure. No evidence of uterine or cervical trauma or complications noted. Empty uterine cavity after the procedure.
Comments (3)
Posted By Melanie Witt on 01-27-2020, 16:24:31
I will repeat that you cannot bill a delivery if the fetus was surgically removed as was described by the op note. ACOG is referring to the natural delivery via labor of a missed abortion after 20 weeks. Again, it is when the fetus is pronounced dead that counts, not when it was delivered as the size of the fetus determines the code.
Posted By Mary Peabody on 01-06-2020, 17:51:33
Hello Melanie,
Hi Melanie
ACOG has a frequently asked questions article regarding coding abortions,

For missed abortion up to 20 weeks, ACOG states to report 59821, however if the fetus demise is 21 weeks, is 59821 still reported?
For incomplete abortion over 20 weeks, ACOG states to report a delivery code.

Surgical Abortion, Missed Abortion or Early Fetal Demise
59820 Prior to 14 wks 0 Days
59821 14 wks 0 Days up to 20 wks 0 Days
Incomplete abortion
59812 Prior to 20 wks 0 days
Complicated by --
Delivery Code 20 wks 0 days or more
Posted By Melanie Witt on 01-04-2020, 15:53:10
As the op note in no way describes a delivery (she would have to be laboring) you use the D&E code for a second trimester missed abortion, 59821. You will also code for the ultrasound guidance using 76998 both linked to O02.1. I assume she was diagnosed as fetal demise before the completion of 20 weeks as the procedure is being done at 21 weeks 2 days.
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