A difficult area of ob/gyn coding is that of selecting the right ICD-9 and CPT codes for the interruption of pregnancy and stillbirth. There are numerous coding choices which will be determined by what you learn from the physician and the documentation concerning the following five issues in the order listed.
1. Identify the cause and/or reason for the interruption of the pregnancy. This will help you determine which diagnosis code to select. Within the ICD-9, the following illustrates some examples of the differentiation between types of abortion. Note that many of these codes require additional digits, which are indicated by an X:
Missed abortion: 632
Intrauterine death: 656.4X
Threatened abortion: 640.0X
Complete or incomplete (spontaneous) abortion: 634.XX
Legally induced abortion (elective, legal, therapeu-
tic): 635.XX
2. You need to know at what point the pregnancy was terminated. This can be an important distinction, as some state legislatures have legally defined the difference between a miscarriage and a stillbirth by the number of weeks: i.e., 16 weeks, 20 weeks or 22 weeks, or by gram weight. This legal definition may determine which CPT codes (i.e. abortion vs. delivery codes) are appropriate for the insurer.
Tip: Your physicians should know the state definitions regarding stillbirth and miscarriage, but if you have questions, a good source for these guidelines would be your state medical examiners office.
3. Identify what services, exactly, were rendered in treating the patient. Where were they performed (office, hospital, or other facility)? As usual, CPT codes cannot be selected until the exact services rendered are documented.
4. Determine whether the patient was in labor before treatment was begun. If so, was labor enhanced, or, was the abortion induced?
5. Finally, at the time treatment begins, the physician must determine and document whether the products of conception were already expelled and whether or not the expulsion was complete.
ACOG Coding Recommendations
Once these questions are answered, then you can begin identifying and selecting the correct CPT codes for the services rendered. The American College of Obstetricians and Gynecologists (ACOG) Committee on Coding and Nomenclature has developed the following coding recommendations for termination of pregnancy:
Surgical management (i.e., D&C or D&E) of incomplete abortion. Defined by ACOG as the expulsion of some products of conception with the remainder evacuated surgically: 59812.
Surgical management (i.e., D&C or D&E) of missed abortion. Defined by ACOG as a pregnancy containing an empty gestational sac, a blighted ovum, or a fetus or fetal pole without a heartbeat prior to 20 weeks 0 days gestation.
Prior to 14 weeks 0 days gestation: 59820.
14 weeks 0 days gestation to prior to 20 weeks 0
days gestation: 59821.
After 20 weeks 0 days: 59821-22 (the 22 is used
to indicate the increased difficulty of the procedure after 20 weeks).
Induced abortion via D&C or D&E (without hospital admission and labor).
Prior to 14 weeks 0 days: 59840.
14 weeks 0 days to prior to 20 weeks 0 days: 59841.
20 weeks 0 days or more by D&E: 59841-22.
Induced abortion via intra-amniotic injections, with hospital admission, visits and delivery.
Prior to 20 weeks 0 days gestation: 59850-59851.
Can be used whether or not fetus has heartbeat prior to delivery.
After 20 weeks 0 days, report maternity care and delivery codes: 59400-59515.
Induced abortion via vagin*l suppositories/cervical dilation, with hospital admission, visits and delivery.
Prior to 20 weeks 0 days gestation: 59855-59857. Can be used whether fetus does or does not have heartbeat prior to delivery.
After 20 weeks 0 days gestation, report the maternity care and delivery codes: 59400-59515.
Medical management of pregnancy using other medical induction agents, and medical management of complete spontaneous abortion.
Prior to 20 weeks 0 days gestation: 99201-99233 (+ 59812 if surgical intervention is necessary to remove the placenta after delivery of the fetus).
vagin*l or cesarean delivery (with or without induction of labor, any method).
20 weeks 0 day's gestation or more: 59400-59515.
Modifier -52 (reduced services) may be appropriate when the number of antepartum visits is substantially less than 13.
Diagnostic possibilites for vagnial or cesarean delivery would be:
640.0X Inevitable abortion or threatened abortion for fetuses 20 weeks 0 days through 21 weeks 7 days.
632 Missed abortion or fetal demise [in utero] for fetuses 20 weeks 0 days through 21 weeks 7 days.
656.4X Intrauterine death after 22 weeks 0 days.
641.XX or 644.XX Inevitable abortion or threatened abortion for 22 weeks 0 days or more.
634.X2 Complete abortion .
Coverage for Elective Abortions
All insurers have policies regarding elective abortion. For instance, Medicare considers elective abortion medically reasonable and necessary under Part B only when the life of the mother would be endangered if the pregnancy were brought to term. Other payers may not cover elective abortions at all. Reimbursem*nt for the services by the insurer may well depend on establishing medical necessity for the abortion service. To prevent payment denials and disputes, it is best to find out the coverage and coding rules of the payer in advance.
