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Posted By Mary Peabody on 01-10-2020, 15:18:54 in Ob-Gyn
Is CPT 59855 Induced abortion by 1 or more vaginal suppositories including hospital admission and visits, delivery of fetus and secundnes? I am not sure if this code is correct because the patient was seen in observation and not admitted as an impatient. The fetus expelled, but the note does not state that the patient was in labor.

_ is a 35yo G3P2 at 15w6d with fetus with multiple anomalies including diaphragmatic hernia with heart displaced into right hemithorax, possible endocardial cushion defect, and hydronephrosis. She also has h/o c/s x 2. Patient presents for induction/termination
 
Patient was consented for procedure and mifepristone was administered on 12/18 . On admission to MB 12/19, consents and plan were confirmed. Patient received 400mcg of misoprostol buccal. She used Toradol and Fentanyl for pain control. Approximately 3 hours after administration of the misoprostol, the fetus was expelled. Cord was clamped and cut and fetus was handed off to be prepared for a viewing with the patient at a later time. Gentle traction was placed on the umbilical cord but the placenta did not deliver immediately. A second dose of misoprostol 400mg buccal was given.
 
Placenta was delivered intact at 2035. Perineum was inspected and no perineal lacerations visualized.
Sponge, lap, and needle counts were correct. Patient tolerated procedure well with no complications.
Comments (1)
Posted By Melanie Witt on 01-27-2020, 15:49:10
In order for her to expel the fetus, she would have had to had labor pains. That is the purpose of the drugs she was given. But in this case I see no evidence that the medication was given via a vaginal suppository so 59855 would not be correct to use. Instead, I would bill just E/M services and prolonged services codes (and be sure to get better timing information to go on as approximately 3 hours does not also cover the additional time for the delivery of the placenta, etc.) You may not bill the delivery of placenta code as there was no surgical intervention.
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