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Reproductive, Intersex Surgery, Female Genital System, and Maternity Care and Delivery List

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Reproductive, Intersex Surgery, Female Genital System, and Maternity Care and Delivery

CHAPTER Chapter Topics
Reproductive System Procedures
Intersex Surgery
Female Genital System
Maternity Care and Delivery

Learning Objectives
After completing this chapter you should be able to
1
Describe reproductive services
2
Report reproductive services
3
Report intersex surgery services
4
Understand the format of the Female Genital System subsection
5
Identify elements of component coding with Female Genital System codes
6
Define the critical terms in maternity and delivery services
7
Define services in the global maternity and delivery package
8
Understand the format of the Maternity Care and Delivery subsection services
9
Demonstrate the ability to code the Female Genital and Maternity Care and Delivery subsection
REPRODUCTIVE SYSTEM PROCEDURES

The Reproductive System Procedures subsection (55920) is located after the Male Genital System subsection and consists of only one code
...
Code 55920 reports the placement of needles or catheters into the pelvic organs and/or genitalia (except prostate) for the subsequent interstitial radioelement application (brachytherapy)
...
This procedure is performed with the patient anesthetized
...
The surgeon examines the diseased areas to determine the area(s) that require treatment
...
A template device is inserted into the vagina and positioned over the areas to receive the radioelement insertions
...
The number and depth of the needles or catheters varies depending on the area to be treated, but typically 32 flexiguide catheters are inserted
...
This code is not used to report radioelement application for the prostate, which is reported with 55875
...
Insertion of a vaginal ovoid brachytherapy system is a common type used to treat cervical cancer and is reported with 57155
...
A Heyman capsule indicated in the parenthetical statement following 55920 directs the coder to 58346 when reporting Heyman capsule insertion
...
A Heyman capsule was a method of manual loading that was used in the early days of brachytherapy
...
The physician would manually insert the capsule into the treatment area, which necessitated the physician being in contact with the radioactive source
...
The newer methods of brachytherapy are safer as the radioelements are inserted via catheters, thus reducing the exposure of health care providers
...
INTERSEX SURGERY
The Intersex Surgery subsection (55970, 55980) is located before the Female Genital Surgery subsection and contains only two codes: one for a surgical procedure to change the sex organs of a male into those of a female and one to change the sex organs of a female into those of a male
...
These specialized procedures include a series of procedures that take place over an extended period of time
...
The procedures are performed by physicians who have special skills and training
...
The procedure for changing male genitalia into female genitalia involves removing the penis but preserving the nerves and vessels intact
...
These tissues are used to form a clitoris and a vagina
...
The urethral opening is shifted to be in the position of that of a female
...
The surgical procedure for changing the female genitalia into male genitalia involves a series of procedures that use the genitalia and surrounding skin to form a penis and testicle structures into which prostheses are inserted
...
FEMALE GENITAL SYSTEM

The Female Genital System subsection (56405-58999) is divided according to anatomic site, from the vulva up to the ovaries (Fig
...
25-1)
...
The anatomic sites are then divided on the basis of category of procedure (i
...
e
...
, incision, excision, destruction)
...
Codes for in vitro fertilization are located at the end of the subsection
...
F I G U R E 2 5 - 1
A, Female genital system
...
B, Anterior view, female genital system
...
C, External female genital system
...
D, Parts of vulva
...
Fallopian tube (oviduct)
Corpus uteri
Cervix uteri
Rectum
Uterine tube
Fundus of uterus
Ampulla
Urinary Ovary bladder Infundibulum
Vagina
Cervix and cervical canal
Vagina
Urethra AB
*Mons pubis
Urethra
Ovary Isthmus
Symphysis pubis
Clitoris
Ligament of ovary
Body of uterus and uterine cavity
with fimbriae
*Labia majora
*Labia minora
Introitus
Bartholin's glands
Perineum *Parts of the vulva
D
*Bulb of vestibule
*Vaginal orifice
*Bartholin's glands
*Parts of the vulva

The subsection has a wide variety of codes for minor procedures that are performed in a physician's office as well as for major procedures that are performed in a hospital setting
...
It is important to read the descriptions of the codes as well as the notes to avoid unbundling in this subsection
...
For example, if a total abdominal hysterectomy was performed as well as a bilateral oophorectomy (removal of ovaries), only 58150 would be reported because the code description includes the statement "with or without removal of ovary(s)
...
" Bundled into the code are both the abdominal hysterectomy and a bilateral oophorectomy
...
There are many screening (well woman) services provided, such as screening mammography, Pap tests, and pelvic examination, in addition to colorectal cancer screening and bone mass measurements
...
In this text, these services are reviewed in the chapter that refers to the codes that would be submitted for the services
...
For example, mammography is in Chapter 28, Radiology
...
Vulva, Perineum, and Introitus
There is a repeated note in the Vulva, Perineum, and Introitus subheading (56405-56821) indicating procedures performed on the Skene's glands are not reported using codes in the Female Genital System subsection but instead are coded using Surgery section, Urinary System subsection codes
...
That is because Skene's glands, also known as para-urethral ducts, are a group of small mucous glands located near the lower end of the urethra and are part of the urinary system
...
Procedures involving Skene's glands are, therefore, reported using Urinary System codes (53060 or 53270)
...
Incision
...
...
The vulva includes the following parts: mons pubis, labia majora, labia minora, bulb of vestibule, vaginal orifice or vestibule of the vagina, and the greater (Bartholin's gland) and lesser vestibule glands (see Fig
25-1, C and D)
...
When the code description indicates the incision and drainage of an abscess of the vulva, the code reports an abscess of any of those anatomic areas
...
For example, if a medical record indicates "an incision and drainage of an abscess of Bartholin's gland," you must know that Bartholin's gland is considered a part of the vulva, so the code will be located in that subheading
...
Destruction
...
...
Destruction of lesions of the vulva, perineum, or introitus can be accomplished using a variety of methods—laser surgery, cryosurgery, electrosurgery, or chemical destruction
Destruction codes are divided on the basis of whether the destruction is simple or extensive, although the code description does not define simple or extensive
...
Complexity is based on the physician's judgment of complexity, and the complexity will be stated in the medical record
...
Excision
...
...
The first two codes (56605 and 56606) in the Excision category are for biopsies in which the physician takes a tissue sample by removing a piece of tissue with a scalpel or punch
The area to be biopsied is anesthetized with local anesthetic before the biopsy is performed
...
The physician may suture the area or use clips for closure
...
The local anesthesia and closure are included in the package of an excision code, so be careful not to unbundle and report these separately
...
The codes are also divided on the number of lesions, one and each additional lesion
...
When using the additional lesions code, be certain to specify the number of lesions biopsied by listing the number of units on the CMS-1500 form in Block 24-G
...
CAUTION
Destruction is not excision
Destruction is obliteration or eradication
...
Excision is removal
...
With destruction no tissue is removed, as the tissue is destroyed
...
There is no pathology report after a lesion has been destroyed because there is nothing for the pathologist to analyze
...
CODING SHOT
If the excision is of a lesion of the skin of the genitalia, report the service with 11420-11426 (Excision of benign lesion) or 11620- 11626 (Excision of malignant lesion)
...
Vulvectomy is the surgical removal of a portion of the vulva
...
Usually a vulvectomy is performed to treat a malignant or premalignant lesion
...
The following definitions apply to the vulvectomy codes (56620-56640) and describe the extent and size of the vulvar area removed during the procedure
...
EXTENT
Simple
skin and superficial subcutaneous tissue
Radical skin and deep subcutaneous tissue


SIZE
Partial less than 80%
Complete greater than 80%

The vulvectomy codes are divided on the basis of these definitions of extent and size
The extent and size are stated in combination
...
For example, simple partial vulvectomy describes a superficial subcutaneous tissue (extent) removal of 78% (size) of the vulvar area
...
Bundled into the codes is usual closure, but if plastic repair is required, you would report the repair in addition to the procedure
...
The operative report will indicate the extent of the procedure and the closure
...
CODING SHOT
There are two labia: labia minora and labia majora (Fig
...
25-2)
...
A partial vulvectomy (less than 80%) pertains to leaving at least 20% of the vulvar area
...
The more radical procedures involving the vulva are usually performed because of a demonstrated malignancy, and more extensive removal takes place
...
This radical removal can include the removal of deep lymph nodes, saphenous veins, ligaments, or large amounts of tissue from the lower abdomen or even from the thigh
...
The procedure may also be performed bilaterally, so don't forget to add modifier -50 when reporting a bilateral procedure
...
CODING SHOT
Most payers do not make a reimbursement adjustment for bilateral procedures of the vulva
...
For example, Medicare does not make an adjustment
...
You must review each payer's guidelines to determine how to submit this code
...
Repair
...
...
The procedure codes in the Repair category (56800-56810) describe plastic repair of the vulva, perineum, or introitus
Plastic repair of the introitus is surgical repair of the opening of the vagina
...
The extent and nature of the procedure are determined by the defect being repaired and varies greatly from patient to patient
...
Clitoroplasty is surgical reduction of a clitoris (Fig
...
25-3) that has become enlarged due to an adrenal gland imbalance
...
Perineoplasty is plastic repair of the perineum, usually to provide additional support to the perineal area
...
Vagina
The Vagina subheading includes the code range 57000-57426
...
Colpotomy (57000-57010) is cutting into the vagina to gain access to the pelvic cavity
...
The procedure is performed to explore the pelvic cavity or to drain a pelvic abscess
...
Colpocentesis (57020) is the insertion of a long needle (puncture) attached to a syringe through the back wall of the vagina to gain access to the peritoneal cul-de-sac—the area between the uterus and the rectum—to drain fluid
...
If the colpocentesis is a part of a more major procedure, you do not report it separately, as it is considered to be bundled into the more major procedure
...
Note that 57020 has "(separate procedure)" after it to designate colpocentesis as a minor procedure that is reported only if it is the only procedure performed of the area
...
Destruction
...
...
As with the destruction codes for the vulva, the destruction codes (57061, 57065) for the Vagina subsection are divided on the basis of whether the destruction was simple or extensive, in the judgment of the physician
Any method of destruction is acceptable for assignment of these codes
...
Excision
...
...
The Excision category of the Vagina subsection contains codes (57100-57135) for reporting the services of biopsy, vaginectomy (removal of part or all of the vagina), colpocleisis (closure of the vaginal canal), and cyst/ lesion removal
The vaginectomy codes are divided according to the extent of the procedure—partial or total—and the extent to which tissue and adjacent structure(s) are removed
...
Introduction
...
...
The Introduction category (57150-57180) contains codes for vaginal irrigation
Also included is the insertion of a tandem and/or vaginal ovoids for brachytherapy
...
The tandems and/or vaginal ovoids are internal implants that contain a radioactive substance and are often used in the treatment of cervical cancer, as illustrated in Fig
...
25-4
...
A tandem is a small, hollow metal tube that is inserted through the vagina into the uterus (intrauterine tandem)
...
Vaginal ovoids are small metal cylinders that are placed into the vagina and positioned against the cervix (intravaginal ovoid)
...
The implants then deliver a concentrated dose of radiation to the site of the tumor
...
Other codes in the Introduction category report the insertion of a support device (pessary, Fig
...
25-5), diaphragm, or cervical cap (to prevent pregnancy)
...
and packing of the vagina (for vaginal hemorrhage)
...
Pessaries are used for vaginal prolapse
...
The pessary and diaphragm/cervical cap are not included in these Introduction codes
...
The supply of these devices would be reported using code 99070, supplies, or a HCPCS code (e
...
g
...
, A4561)
...
Repair
...
...
The Repair category (57200-57335) is rather extensive, as the possible forms of repair of the vagina are many
A note in parentheses, "(nonobstetrical)," sometimes follows the code description in the Female Genital System subsection because if the procedure was performed as a part of an obstetric procedure, you would use a code from the Maternity Care and Delivery subsection
...
A surgeon performs a colporrhaphy to strengthen an area on the wall of the vagina that is weak by pulling together the weakened vaginal area with sutures
...
Excess tissue can also be removed to tighten the area
...
The reinforcement might be performed for several reasons, but it is commonly done to prevent the bladder from protruding into the weakened vaginal wall (cystocele) or the rectum from protruding into the vagina (rectocele)
...
In this Repair category, the codes are often divided on the basis of the approach used
...
For example, an abdominal approach (open, 57270) to the repair of an enterocele (herniation of intestines through intact vaginal mucosa) has a different code than a vaginal approach (57268) to the same repair
...
and an anterior colporrhaphy (vaginal repair) (57240) differs from a posterior colporrhaphy (57250)
...
Pay particular attention to the approach used
...
You will find the approach documented in the operative report
...
One method of vaginal repair that is not in the Repair category is the laparoscopic repair
...
Codes for repair of the vagina using a colposcope (microscope) are located in the Vagina subheading, Endoscopy category
...
The colposcope enables the physician to directly view changes in the vagina and cervix
...
Notes throughout the Repair category will frequently direct you to the correct code or code range in the Urinary System subsection
...
Often, the only difference between surgical procedures reported with Female Genital System codes and those reported with the Urinary System codes is the approach
...
For example, Female Genital System code 57330 describes the closure of a vesicovaginal fistula (abnormal channel between bladder and vagina) using a vaginal approach, whereas Urinary System code 51900 describes the same procedure using an abdominal approach
...
The approach would be documented in the operative report
...
Manipulation
...
...
Manipulation of the vagina includes dilation (stretching), pelvic examination, and removal of foreign material
What these three different procedures have in common is that they are all performed under general anesthesia because a patient cannot tolerate the procedure while awake
...
If a local anesthetic or no anesthetic was used, which is the usual case, you would not use a Manipulation code (57400-57415)
...
instead, the service would be included in the Evaluation and Management (E/M) service
...
For example, if a physician removed an impacted tampon from the vagina and used no anesthetic during the procedure, only the office visit at which the removal took place would be reported
...
Endoscopy
...
...
As discussed earlier in this chapter, the endoscopic procedure codes (57420-57426) in the Endoscopy category of the Vagina subheading are for colposcopic procedures
The colposcopic procedures are often bundled into other, more major procedures
...
Fig
...
25-6 illustrates an endocervical polyp protruding through the external os (mouth of the cervix) as seen by the physician using a colposcope
...
Only when a colposcopic procedure is performed as the only procedure or is unrelated to another procedure(s) being performed is the colposcopy reported
...
If a biopsy of the vagina or cervix is performed with colposcopy, the code to report the service is 57421
...
The code specifies "biopsy(s)," so whether one or multiple biopsies were taken, 57421 represents the total service
...
CAUTION
Coders need to pay close attention to the method as well as to the approach
For example, a surgeon might perform an open procedure as opposed to a laparoscopic procedure
...
Cervix Uteri
The Cervix Uteri subheading contains codes (57452-57800) for endoscopy, excision, repair, and manipulation
...
Endoscopy
...
...
Similar to the vaginal endoscopic codes, the colposcopy codes report procedures of the cervix uteri (57452-57461)
A loop electrode excision procedure is referred to as LEEP, LETZ, or cervical loop diathermy and is an office procedure that uses heated wire (Fig
...
25-7) to remove cervical tissue
...
The device is attached to an electric generator that heats the wire
...
The procedure has a lower risk level and is less expensive than other methods
...
A LEEP would usually be performed after an abnormal Pap smear result or an abnormal examination
...
The cervix is moistened, and the loop is positioned over the cervix and drawn across the area
...
The resulting slice is examined by a pathologist
...
The device is also used to cauterize the area at the end of the procedure by means of a different attachment
...
Excision
...
...
The codes in the Excision category often specify "(separate procedure)" because many times the procedures are bundled into a more major procedure
For example, the excision procedure of a biopsy is often incidental to a more major surgical procedure, such as a hysterectomy, and the biopsy would not be reported separately
...
Codes for conization of the cervix are divided on the basis of the method used to obtain the tissue (Fig
...
25-8)
...
In conization, a cone of tissue is removed from the cervix for a biopsy or treatment of a lesion by means of excision of the lesion
...
Although a laser is a frequently used method of conization, LEEP technology is also widely used
...
The code for a LEEP procedure with cervical biopsy in the Cervix Uteri subheading, Endoscopy category, is 57460, and the code for a LEEP procedure with cervical conization is 57461
...
The difference between the codes is that the cervical biopsy procedure only removes a sample with return in the future if the lesion is to be completely removed
...
The conization procedure removes a cone-shaped tissue of the cervix after application of iodine to highlight the abnormal tissue
...
Also, the cervical biopsy is performed with the use of a colposcope (endoscopy), and the conization is performed using a speculum (Fig
...
25-9) (an instrument inserted into a cavity to stretch the opening)
...
Be certain, when coding cervical biopsy and conization, that the information in the medical record provides sufficient detail to allow you to distinguish between a biopsy and a conization
...
If the record is not complete enough to make the determination, obtain the information from the physician before assigning a code
...
Repair
...
...
Nonobstetric cerclage (repair of the cervix) involves extensive suturing of the cervix to decrease the size of the opening into the vagina (reported with 57700)
Trachelorrhaphy (57720) is a complex cervical repair in which plastic methods are used to repair a laceration of the cervix
...
Both Repair codes use a vaginal approach
...
Manipulation
...
...
Dilation of the cervix is coded separately only if it is the only procedure performed (57800)
Dilation of the cervix, like dilation of the vagina, is usually bundled into a more major procedure
...
Corpus Uteri
The corpus uteri (58100-58579) is the anatomic area above the isthmus and below the opening for the fallopian tubes
...
The subheading contains the categories of excision, introduction, repair, and laparoscopy/hysteroscopy procedures
...
Many of the procedures in the category are very complex, and some of them have several variations
...
Let's review some of the highlights of corpus uteri coding
...
Excision
...
...
Endometrial sampling is a biopsy of the mucous lining of the uterus
The physician inserts a curet (spoon-shaped instrument) into the endocervical canal to extract tissue samples for pathologic examination
...
If the sampling is the only procedure performed, it is reported (58100, 58110), but if it is performed as part of a more major procedure involving the cervix, it is considered incidental to the more major procedure and is bundled into the surgical package
...
Dilation and curettage (D&C
...
58120) can be a diagnostic or therapeutic procedure performed when an endometrial biopsy has failed or was inconclusive or to determine the cause of abnormal bleeding or locate a neoplasm
...
Clamps are used to manipulate the cervix, a curet is inserted into the uterus, and fragments are removed from the endometrium
...
The tissue is sent to pathology for analysis
...
D&C in the Corpus Uteri subheading is for nonobstetric patients only
...
If a D&C is performed because of postpartum hemorrhage, a code from the subsection Maternity Care and Delivery would be assigned to report the service (59160)
...
CODING SHOT
Many third-party payers will not reimburse for a dilation and curettage if it is performed with any other pelvic surgery because it is thought to be integral to or a part of the procedure
...
The CPT manual does not list a D&C as a "(separate procedure)"
...
therefore, you need to be familiar with the specific reimbursement policies of the payer
...
CODING SHOT
The cost of the IUD is not included in the code for the insertion of the IUD
...
You report the cost of the device separately, using 99070 or a HCPCS code (J7300 or S4989)
...
Hysterectomy codes (58150-58294) represent the majority of the codes in the Corpus Uteri subheading
...
A hysterectomy is the removal of the uterus, but in the CPT manual there are many variations of this procedure
...
The division of the hysterectomy codes is based first on the approach (abdominal or vaginal), then on the secondary procedures (extent) that were performed (removal of tubes, biopsy, bladder, etc
...
)
...
You have to read the code descriptions carefully to determine what is bundled into each code
...
Because so many procedures are bundled into some of the codes, you also have to be careful not to unbundle and code for items already covered in the main procedure
...
For example, a total abdominal hysterectomy can include the removal of the ovaries and/or the fallopian tubes
...
therefore, billing separately for the removal of the ovaries or tubes would be unbundling
...
Within the Excision category there are codes for abdominal approaches for hysterectomies
...
An abdominal approach is one in which the surgeon opens the abdomen to view by means of an incision
...
Review the codes in the range 58150-58240 and underline "abdominal" in each of the codes as a reminder of the approach used in these codes
...
The other type of surgical approach for hysterectomies listed in the Excision category is the vaginal approach
...
Using the vaginal approach, the surgeon makes an incision in the vagina around the cervix and removes the uterus and/or ovaries/fallopian tubes (salpingo-oophorectomy) through the incision
...
The cuff of the vagina is then closed with sutures
...
Review the codes in the range 58260-58294 and underline "vaginal" as a reminder of the approach used in these codes
...
Introduction
...
...
It is in the Introduction category (58300-58356) that you will locate the codes for some very common procedures such as the insertion and removal of an intrauterine device (IUD), as illustrated in Fig
25-10, for birth control and for some not-so-common procedures such as artificial insemination
...
There are also several codes that have radiology components—your component coding skills will again be used
...
Because intrauterine device (IUD) insertion is reported using Introduction category code 58300, you might think IUD removal would be in a removal category, but it is in the Introduction category (58301)
...
Don't confuse the insertion of an IUD with the placement of an implantable contraceptive such as Norplant, as described in the Integumentary subsection
...
The specialized fertility procedure of artificial insemination (58321- 58323) and the preparation of the sperm for insemination are reported with Introduction category codes
...
During the insemination procedure, sperm is injected into the cervix and often a cervical cap is inserted to keep the sperm in the cervical area
...
In vitro fertilization is a different procedure in which an egg from the female is withdrawn and fertilized with sperm in a laboratory for 2 to 3 days with subsequent implantation into the uterus
...
There is an In Vitro Fertilization subheading containing codes 58970-58976 to report these services, located at the end of the Female Genital System subsection
...
Catheterization and introduction (58340) of saline or contrast material through the cervix and uterus and into the fallopian tubes (hysterosalpingography) is performed by a physician to identify blockage or abnormalities of the fallopian tubes
...
Ultrasound can also be used for the same procedure (hysterosonography)
...
You need to remember your component coding and report the radiology or ultrasound portion of the procedure with a code from the Radiology section
...
A note following 58340 in the CPT manual directs you to the correct component code
...
For the radiographic supervision and interpretation, the component code is 74740
...
for the ultrasound (sonohysterography), the code is 76831
...
A hysterosalpingography is a diagnostic procedure to test the patency (unblocked) of the fallopian tubes
...
Saline or contrast material is injected into a tube (58340)
...
A catheter may be introduced (58345) and passed through the fallopian tube using x-ray to show where the catheter encounters an obstruction or a narrowing of the tube
...
A code from the Radiology section, Gynecological and Obstetrical subsection, would report the radiology portion of the service (74742)
...
Chromotubation (58350) is a surgical procedure to open an obstructed or narrowed tube
...
Laparoscopy/Hysteroscopy
...
...
An increasing number of procedures are being performed by using an endoscope instead of opening the area to complete view
With an endoscopic procedure, usually two or three small incisions are made through which lights, cameras, and instruments may be passed
...
The surgeon first inserts an instrument into the vagina to grasp the cervix
...
The laparoscope is then inserted into the abdomen and the uterus and/or ovaries/fallopian tubes are excised
...
An incision is made in the vagina and the surgically excised material is removed through the vaginal incision
...
The vagina is then repaired by means of sutures
...
Review the codes in the range 58541-58579 and underline "Laparoscopy" or "Hysteroscopy" as a reminder of the approach used in these codes
...
It is very important to read the full code description to identify the approach
...
Because endoscopic procedures are less invasive, patients are more accepting of the procedures, and recovery times and risks are reduced
...
Fig
...
25-11 illustrates a laparoscopy procedure and Fig
...
25-12 illustrates a laparoscopy/hysteroscopy procedure
...
The first rule of a laparoscopy or hysteroscopy is that all surgical procedures include a diagnostic procedure
...
You never unbundle a surgical laparoscopic procedure by also reporting a diagnostic procedure
...
If a procedure started out as a diagnostic laparoscopic procedure and ended up being a surgical laparoscopic procedure, you report only for the surgical laparoscopy
...
The codes in the Laparoscopy/Hysteroscopy category are divided on the basis of approach—laparoscopy or hysteroscopy—and further divided by other procedures that might have been performed
...
CAUTION
If the laparoscopy is of the peritoneum, you assign a code (49320) from the laparoscopy category of the Digestive System, Abdomen, Peritoneum, and Omentum subheading
Oviduct/Ovary
The Oviduct/Ovary subheading (58600-58770) is divided into incision, laparoscopy, excision, and repair
...
Fallopian tube procedures are located in this subheading
...
Incision
...
...
The Incision category is where you will locate the codes for tubal ligation, which is a permanent, highly effective method of birth control
The codes are divided according to the type of ligation performed and the circumstances at the time of the ligation
...
The types of ligation are as follows: tying off the tube with suture material (ligation), removing a portion of the tube (transection), and blocking the tube with a device, such as a clip, ring, or band (occlusion)
...
The circumstance under which the procedure is performed affects the choice of codes
...
For example, a procedure can be performed either on one side (unilateral) or on both sides (bilateral)
...
The procedure can be performed at different times, such as during the same hospitalization period as the period of delivery, during the postpartum period, or during another surgical procedure and these circumstances affect code assignment
...
CODING SHOT
Do not use a bilateral procedure modifier (-50) with codes in the Incision category because the code descriptions indicate "tube(s)" or "unilateral or bilateral
...
" Also, do not code tubal ligations performed by means of a laparoscopic procedure using the Incision category codes
...
There are codes for laparoscopic tubal ligation procedures in the Laparoscopy category of subheading Oviduct/Ovary (58660-58679)
...
CODING SHOT
58740, lysis of adhesions, is performed for restoration of fertility, not for lysis of adhesions at the time of tubal ligation (such as 58660)
...
A ligation can be performed by an abdominal or a vaginal approach
...
If a ligation or transection of the fallopian tube(s) is performed during the same operative procedure as a cesarean delivery or other intra-abdominal surgery, you report the ligation/transection using 58611
...
Code 58611 only reports the tubal ligation as a component of the more major surgical procedure and is listed in addition to the primary code
...
Often at the time of an abdominal tubal ligation, lysis (loosening) of adhesions will be performed
...
Lysis is not bundled into the ligation code
...
You report the lysis of adhesions separately, using a Repair category code such as 58660, if allowed by the third-party payer
...
Laparoscopy
...
...
The procedures described in the Oviduct/Ovary subheading, Laparoscopy category (58660-58679) are surgical laparoscopy and always include a diagnostic laparoscopy
If only a diagnostic laparoscopy was performed, you report 49320 from the Digestive System subsection, Abdomen, Peritoneum, and Omentum category, because the scope is being passed into the abdomen for examination only
...
Once a definitive procedure such as a tubal ligation has begun, the examination/diagnostic laparoscopic procedure is bundled into the surgical procedure
...
For example, if a diagnostic laparoscopy was performed and did not lead to a definitive procedure, the diagnostic laparoscopic code 49320 from the Digestive System subsection would be reported to describe the procedure of examining the abdomen using an endoscope
...
But if a diagnostic laparoscopy was performed and did lead to a fulguration of the oviducts, code 58670 from the Female Genital System subsection would be assigned
...
The terminal (end or final) procedure dictates the code choice
...
The laparoscopy codes are divided on the basis of the procedure performed, for example, lysis of adhesions, oophorectomy, and lesion excision
...
Excision
...
...
The Excision category codes report salpingectomy (removal of uterine tube) or salpingo-oophorectomy (removal of uterine tube and ovary) and describe unilateral or bilateral procedures that are either complete or partial
An unbundling issue presents itself with the assignment of these codes
...
If either a salpingectomy or salpingo-oophorectomy is performed with a more major procedure such as a hysterectomy, each is considered bundled into the more major procedure and not reported separately
...
Repair
...
...
Within the Repair category are codes for lysis of adhesions and various repairs to the fallopian tubes
All of the repairs are performed for the purpose of restoring fertility
...
Often the repairs are made through small incisions above the pubic hairline, but they can also be performed through a laparoscope, so note the approach used for repairs to the fallopian tubes
...
Lysis of adhesions performed on the fallopian tubes (salpingolysis) or the ovaries (ovariolysis) uses a small incision to insert instrumentation to complete the repairs
...
Lysis is a procedure that is often performed at the time of another, more major procedure and is usually bundled into the more major procedure
...
If the lysis takes an extensive amount of time, you can report the service separately with supportive documentation indicating the additional time and effort required to perform the lysis
...
Another option is to report modifier -22 to indicate that the procedure required more time than normal
...
The time to complete the lysis portion of the procedure must be clearly documented in the operative report
...
Ovary
The subheading Ovary (58800-58960) contains the two categories Incision and Excision
The Incision codes report ovarian incision and drainage
...
The Excision codes report ovarian biopsy, cystectomy, and oophorectomy procedures
...
In Vitro Fertilization

In vitro fertilization means to fertilize an egg outside the body
...
The codes in the In Vitro Fertilization category describe several methods that are used in modern fertility practice
...
Third-party payers often do not pay for the fertility treatments
...
You will have to be certain that you know the policy of the payer regarding fertility treatments
...
Code 58970, aspiration of the ova, is often performed with ultrasonic guidance and when it is, assign 76948 (Radiology section, Ultrasonic Guidance Procedures) to report the service
...
MATERNITY CARE AND DELIVERY
The Maternity Care and Delivery subsection (59000-59899) is divided according to type of procedure
As a general rule, the subsection progresses from antepartum procedures through delivery procedures
...
The guidelines are very detailed as to the services included in antepartum and delivery care, not only to facilitate coding but also to help guard against unbundling
...
Notes at the beginning of this subsection describe, in depth, the services listed in obstetric care
...
Be certain to read these notes
...
Abortion codes, whether for spontaneous abortion, missed abortion, or induction of abortion, are at the end of the subsection
...
Abortion codes indicate treatment of a spontaneous abortion or missed abortion, including additional division on the basis of trimester and induction of abortion by method
...
You must be aware of the gestational age of the fetus to determine the correct code
...
Treatment for ectopic pregnancies is based on the site of the pregnancy, the extent of the surgery, and whether the approach was by means of laparoscopy or laparotomy (incision through abdominal wall)
...
Maternity and Delivery
The gestation of a fetus takes approximately 266 days
but when the estimated date of delivery (EDD) is calculated, 280 days are often used, counting the time from the last menstrual period (LMP)
...
The gestation is divided into three time periods, called trimesters
...
The trimesters are as follows:
n
First LMP to week 12
n Second Weeks 13-27
n ThirdWeeks 28-EDD

When a maternity case is uncomplicated, the service codes normally include the antepartum care, delivery, and postpartum care in the global package
Antepartum care is considered to include both the initial and subsequent history and physical examinations, blood pressures, patient's weight, routine urinalysis, fetal heart tones, and monthly visits to 28 weeks of gestation, biweekly visits from gestation weeks 29 through 36, and weekly visits from week 37 to delivery when these services are provided by the same physician
...
If the patient is seen by the same physician for a service other than those identified as part of antepartum care, you would report that service separately
...
For example, if a patient in week 32 came to the office with a chief complaint of cold symptoms, an E/M service code would be reported for the service and the diagnosis code would further indicate that the service was provided due to a cold not pregnancy
...
Admission to the hospital is bundled into the delivery codes and includes the admitting history and examination, management of an uncomplicated labor, and delivery that is either vaginal or by cesarean section (including any episiotomy, illustrated in Fig
...
25-13, and use of forceps, as illustrated in Fig
...
25-14)
...
Included in postpartum care are the hospital visits and/or office visits for 6 weeks after a delivery
...
If the postpartum care is complicated or if services provided to the patient during the postpartum period are not generally part of the postpartum care, you would report those additional services separately
...
Routine Obstetric Care
There are four codes that describe the global routine obstetric care that includes the antepartum care, delivery, and postpartum care, based on the type of delivery:
59400 Vaginal delivery

59510 Cesarean delivery

59610 Vaginal delivery after a previous cesarean delivery

59618 Cesarean delivery following attempted vaginal delivery after previous cesarean delivery

Two abbreviations commonly found on the delivery record are VBAC (vaginal birth after cesarean) and VBACS (vaginal birth after cesarean section), which assist in assigning the correct code
...
FIGURE
25-13
Infant Head
Midline Episiotomy
Midline (median) episiotomy
CODING SHOT
Bundled into the vaginal delivery codes are an episiotomy (cutting of the perineum) and/or the use of forceps during delivery and, therefore, neither is reported separately
...
If the physician provided only a portion of the global routine obstetric care, the service is reported with codes that describe that portion of the service as delivery only or postpartum care only, based on the delivery method
...
For example, if a physician provided only the delivery portion of the service, you would report the service with:

59409 Vaginal delivery only

59514 Cesarean delivery only

59612 Vaginal delivery only, after previous cesarean delivery

59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery

If the global obstetric care is provided and twins are delivered, the same codes are reported but, depending on the third-party payer, modifier -22 (Increased Procedural Services) or -51 (Multiple Procedures) is added
...
Usually, if both twins are delivered vaginally, report 59400 for Twin A and 59409-51 for Twin B
...
If one is delivered vaginally and one is delivered cesarean, report 59510 for Twin B and 59409-51 for Twin A
...
If both are delivered via cesarean, report only 59510 (because only one cesarean was performed)
...
Some payers, such as Medicaid in Illinois and Texas, require 59409 (vaginal delivery) or 59410 (cesarean delivery) to be reported since they do not recognize the global obstetric care codes
...
Each prenatal visit and the delivery is billed separately
...
Just another reminder that knowledge of the payers' rules will ensure prompt and proper payments
...
Delivery Method
Code for TWIN A Code for TWIN B

Both twins delivered vaginally 59400 59409-51

One twin delivered vaginally 59409-51 59510
Other twin delivered cesarian

Both twins delivered cesarian 59510



Antepartum Services
Amniocentesis (59000, 59001) is a procedure in which the physician inserts a needle into the pregnant uterus to withdraw amniotic fluid and is only performed after the first 14 weeks of pregnancy
In this procedure, ultrasound is used to guide the needle, and the supervision and interpretation (S&I) service is reported using 76946 from the Radiology section, Ultrasonic Guidance Procedures subsection
...
Several of the antepartum services require component coding in order to fully report the services provided
...
Attention to the code descriptions and parenthetic statements is necessary to ensure that all services are reported
...
Cordocentesis (59012) is a procedure in which fetal blood is drawn
...
This procedure is performed under ultrasonic guidance to assess the status of the fetus
...
Cordocentesis is not included in normal antepartum care and should be reported separately
...
The ultrasonic guidance (76941) would also be reported separately
...
Excision
...
...
Abdominal hysterotomy (59100) may be performed to remove a hydatidiform mole (cystlike structure) (Fig
25-15) or an embryo
...
If a tubal ligation is performed at the same time as a hysterotomy, be certain to report 58611 to indicate the ligation
...
An ectopic pregnancy is one in which the fertilized ovum has become implanted outside of the uterus, as illustrated in Fig
...
25-16
...
The surgical treatment for this condition can use either an abdominal or a vaginal approach (59120-59150)
...
most often, the abdominal approach is used
...
If the area has not ruptured, the pregnancy is removed
...
If a rupture has occurred, a more extensive procedure is required
...
You have to identify the location of the ectopic pregnancy, the extent of the necessary repair, and the approach to the repair—vaginal, abdominal, or laparoscopic—to correctly code the procedure
...
Postpartum curettage is performed within the first 6 weeks after delivery to remove remaining pieces of the placenta or clotted blood
...
Code 59160 is only for use with postpartum curettage
...
If the curettage is nonobstetric, report 58120
...
F I G U R E
2 5 - 1 6 Implantation sites of ectopic pregnancy
Ampulla
Isthmus
Interstitium
Tubo-ovarian ligament
Internal cervical
Ovary
Abdominal viscera
Fimbria

CODING SHOT
Radiological procedures require a separate medical document before you can submit for reimbursement
...
Modifier -26 may be required depending on where the service was performed and who owned the radiology equipment
...
Introduction
...
...
A cervical dilator (such as laminaria, which is a compound on a stick that swells from surrounding moisture) may be inserted prior to a procedure in which the cervix is to be dilated
it prepares the cervix for an abortive procedure or a delivery
...
The dilator initiates uterine contractions, which in turn cause cervical dilatation
...
Induction can be elective—at the convenience of the patient or the physician—or required, based on a medical risk factor to the mother or fetus
...
Physicians use a scoring system to measure the stage of cervical ripening, as illustrated in Fig
...
25-17
...
To induce cervical ripening (softening and dilation), a preparation such as Prepidil gel is introduced intracervically using a catheter
...
The cervical ripening takes place in the delivery ward
...
Many third-party payers will not pay separately for an induction procedure, as it is considered to be part of the package for obstetric care
...
You will have to check with your payers to determine their policies regarding the induction procedure
...
Repair
...
...
The obstetric repairs can be to the vulva, vagina, cervix, or uterus
All of these repairs are also located in the Female Genital subsection, but here in the Maternity Care and Delivery subsection, the codes are reported only for repairs made during pregnancy
...
Repairs made during delivery or after pregnancy are included in the delivery codes 59400-59622
...
CODING SHOT
You can report 59200 (cervical ripening) with an induced abortion (59840 or 59841) but not with an abortion induced by means of vaginal suppositories (59855-59857)
...
Also, do not report an induction procedure using a code that describes a manual dilation as a part of the procedure, such as D&C
...
CODING SHOT
Vaginal repairs can be reported separately only by a physician other than the attending physician
...
When the attending physician performs a procedure such as an episiotomy, it is considered part of the package for obstetric care
...
Each third-party payer determines what is included in the obstetric package
...
Abortion Services
...
...
The abortion codes (59812-59857) include services for treatment for several types of procedures
A spontaneous abortion (miscarriage) is one that happens naturally
...
If the uterus is completely emptied during the miscarriage and the physician manages the postmiscarriage, the services are reported with E/M codes
...
Sometimes the abortion is incomplete and requires intervention to remove the remaining fetal material (59812)
...
A missed abortion is one in which the fetus has died naturally sometime during the first half of the pregnancy but remains in the uterus
...
The physician removes the fetal material from the uterus and reports the service based on the trimester in which the service was provided (59820- 59821)
...
A septic abortion, whether induced or missed, has the added complication of infection
...
The physician removes the fetal material from the uterus and vigorously treats the infection (59830)
...
The induced abortions are those in which the death of the fetus is brought about by medical intervention (59840-59857)
...
One of three methods is used: dilation with either curettage (scraping) or evacuation (removal by means of suction), intra-amniotic injections, or vaginal suppositories
...
The selection of the code depends on which of the three methods was used to accomplish the abortion
...
Dilation and curettage is a procedure in which the cervix is dilated and the fetal material is scraped out by means of a curet
...
When the dilation and evacuation method is used, the cervix is dilated and the contents are suctioned out by means of a vacuum aspirator
...
The intra-amniotic injections are of urea or saline, which induces an abortion
...
Vaginal suppositories (such as prostaglandin) can be inserted into the cervix, with or without cervical dilation, to induce an abortion
...
A hysterotomy (cutting into the uterus, 59857) may be performed if the medical intervention by injection or vaginal suppositories fails
...
STEP BY STEP
BOOK I COMPLETE


INTRODUCTION TO CPT CODING
BOOK II


Surgery: Female Genital System
Section Objectives
Understand the codes for reporting procedures performed on the female genital system
Understand the difference between open and hysteroscopic procedures
Understand the global maternity care concept
Undertand the different types of abortion
The Female Genital System subsection includes codes for reporting procedures on the vulva, perineum, and introitus (codes 56405-56821)
...
vagina (codes 57000-57426)
...
cervix uteri (codes 57452-57800)
...
corpus uteri (codes 58100-58579)
...
oviduct/ovary (codes 58600-58770)
...
and ovary (codes 58800-58960) as well as in vitro fertilization (codes 58970-58976)
...
(See Figure 4-96
...
)
FIGURE 4-96 Female Genital System

Vulvectomy
Vulvectomy is performed on the external genitalia of the female
...
Definitions for simple, radical, partial, and complete vulvectomy are included under the Vulva, Perineum, and Introitus heading of the CPT codebook
...
They include the following:

Simple vulvectomy: Removal of skin and superficial subcutaneous tissues
Radical vulvectomy: Removal of skin and deep subcutaneous tissue
Partial vulvectomy: Removal of less than 80% of the vulvar area
Complete vulvectomy: Removal of more than 80% of the vulva

A patient has cancer of the vulva
...
Portions of the vulva are removed including the outer skinfolds of the vulva and the clitoris and terminal portions of the urethra, vagina, and other vulvar structures
...
CPT code 56630, Vulvectomy, radical, partial, describes this surgery
...
1
...
Name the different vulvectomy procedures
...
• Hysteroscopy
Hysterectomy
Various hysterectomy procedures are described under the headings Corpus Uteri and Ovary
...
The extent of the procedure performed should be clearly documented in the operative report
...
Removal of the fallopian tube(s) and/or ovary(s) or ovaries when performed with an abdominal hysterectomy procedure is not reported separately because the code descriptors for abdominal hysterectomy procedures include the language "with or without removal of tube(s), with or without removal of ovary(s)
...
" In addition, if an enterocele or urethrocystopexy repair is performed at the same session as a vaginal hysterectomy procedure, it should be determined whether the appropriate codes in the 58260-58294 series are available before referring to procedures from the 57200-57330 series of codes
...
Hysterectomies can be abdominal (58150-58210, 58951, 58953, 58956), vaginal (58260-58294), or laparoscopic (58541-58544, 58548-58554)
...
(See Figures 4-97 and 4-98
...
)
Laparoscopic/Hysteroscopic Surgery
The CPT code series 58541-58579 reports laparoscopic and hysteroscopic surgeries that occur on the uterus
...
Code series 58660-58679 reports laparoscopic surgeries on the oviduct or ovaries
...
FIGURE 4-97 Total Abdominal Hysterectomy, With or Without Removal of Tube(s), With or Without Removal of Ovary(s)

When laparoscopic procedures are performed, a small surgical incision (cut) is made in the abdominal wall to permit the laparoscope to enter the abdomen or pelvis so that internal structures can be viewed
...
Tubes and probes are then introduced through the incision
...
This allows surgical procedures to be performed without the need for a large surgical incision
...
A surgical laparoscopy always includes a diagnostic laparoscopy
...
FIGURE 4-98 Vaginal Hysterectomy, With Total or Partial Vaginectomy
...
With Repair of Enterocele

The following steps will assist in selecting the appropriate CPT code to report when a laparoscopic procedure is performed:

Look up laparoscopy in the index, and locate the organ and/or system being examined or treated using a scope
...
Look at the codes in that system/organ section to find a laparoscopy heading
...
If there is a laparoscopy heading in that section, look for a code with a descriptor that includes a suffix -oscopy and describes the procedure performed
...
If there is no heading of laparoscopy or there is no specific code describing the use of a scope in its descriptor, the codes described in that section are "open" surgical procedures and should not be used to report a procedure using a laparoscope approach
...
Clarify with the physician that the procedure was performed using a laparoscope
...
If it is determined that there is no specific code for the laparoscopic procedure one is attempting to code, the unlisted procedure laparoscopy code is used to report the procedure
...
If there is no specific unlisted laparoscopy code, use the general unlisted procedure code from the appropriate anatomic subsection of the CPT codebook
...
When reporting an unlisted code to describe a procedure/service, a copy of the operative report should be submitted to the insurance company with the claim
...
Hysteroscopy: Visual instrumental inspection of the uterine cavity
...
(See Figure 4-99
...
)

It is not appropriate to report the "open" procedure code to describe a procedure performed laparoscopically
...
The following is an example of a laparoscopic procedure performed on the ovary:
58661
Laparoscopy, surgical
with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)
The code series 58600-58770 (oviduct/ovary) is intended to report procedures involving ligation or transection of fallopian tube(s), tubal ligation, and occlusion of the fallopian tube(s) by device
...
The following is an example of a procedure performed on the fallopian tube(s)
...
58600
Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate procedure)
FIGURE 4-99 Hysteroscopy


Codes designated as separate procedures may be additionally reported when the procedure or service is performed as an integral component of another procedure or service
The code series 58800-58960 is intended to report procedures performed on the ovary including biopsy, resection, cyst removal, and excisions in instances of tubal, ovarian, or peritoneal malignancy
...
Some of the codes listed in this section include the phrase, "separate procedure" in the code descriptor
...
This designation indicates that the procedure may be considered an integral component of another procedure/service, performed independently, unrelated, or distinct from other procedure(s)/service(s) provided at that time
...
Integral Component
58720
Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)
58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s)
When reporting a total abdominal hysterectomy with removal of the tube(s) and ovary(s) or ovaries, it would not be appropriate to separately report code 58720 in conjunction with code 58150
This would be considered unbundling
...
The procedure described by code 58720 is considered an integral component of the procedures described by code 58150
...
However, codes designated as separate procedures should be additionally reported when performed independently, unrelated, or distinct from other procedure(s) or service(s) provided
...
In Vitro Fertilization
There is a separate series of CPT codes (58970-58976) used for reporting procedures related to in vitro fertilization, procedures performed by the physician in which egg cells are fertilized outside the woman's body
...
Code 58970 describes follicle puncture for oocyte retrieval, any method
...
code 58974 describes embryo transfer, intrauterine
...
and code 58976 describes gamete, zygote, or embryo intrafallopian transfer, any method
...
In vitro fertilization: Procedures in which egg cells are fertilized outside the woman's body
...
If ultrasound guidance for aspiration of ova is used, CPT code 76948 is coded in addition to 58970
...
Maternity Care and Delivery
The services normally provided in uncomplicated maternity cases include routine antepartum care, delivery, and postpartum care
...
This is the global obstetric package for maternity care and delivery
...
The guidelines at the beginning of the Maternity Care and Delivery subsection in the CPT codebook define the services included when antepartum care, delivery services, and postpartum care are reported
...
(See Figure 4-100
...
)
Maternity patients are described by the number of pregnancies (including previous and current) and the number of births
...
Gravida refers to the number of pregnancies a women has had, a woman pregnant for the first time is referred to as a primigravida (or gravida I), during the second pregnancy gravida II or secundigravida, during the third pregnancy gravida III or tertigravida
...
The number of pregnancies that have resulted in the birth of viable offspring is referred to as para, followed by a Roman numeral to designate the number of pregnancies (eg, para 0 is no births yet
...
para I is one birth
...
para II is two births, etc)
...
Since the number indicates how many pregnancies, a multiple birth counts as just one in the calculation
...
See the following example:

• Antepartum care
• Postpartum care
• Primigravida
• Para
• Gravida

Gravida 1, Para 0 (G1P0) means the first pregnancy, which has not resulted in the birth yet
...
Gravida 3, Para 2 (G3P2) means the third pregnancy, two previous births
...
FIGURE 4-100 Vaginal Delivery


Antepartum care: Care during the first trimester
...
Postpartum care: Care following delivery
...
Primigravida: A woman pregnant for the first time
...
also written gravida I
...
Para: A woman who has produced viable young regardless of whether the child was living at birth
...
Used with Roman numerals to designate the number of pregnancies that have resulted in the birth of viable offspring, as para 0 (none), para I (one), para II (two), para III (three), para IV (four), etc
...
Since the number indicates how many pregnancies, a multiple birth counts as just one in the calculation
...
Gravida: A pregnant woman
...
Called gravida I or primigravida during the first pregnancy
...
Global Services for Routine Obstetric Care
Antepartum care includes the following:

The initial and subsequent history
Physical examinations
Recording of weight, blood pressures, and fetal heart tones
Routine chemical urinalysis
Monthly visits up to 28 weeks' gestation, biweekly visits to 36 weeks' gestation, and weekly visits until delivery
The E/M services (visits) provided with those services included in the provision of antepartum care are not separately reported
...
However, any other visits or services provided within the antepartum period, other than those listed above, should be coded and reported separately
...
When the same physician (solo practice) or same physician group (group practice) provides the global routine obstetric care (including antepartum care, delivery, and postpartum care), the appropriate global code is reported to describe the services rendered
...
Codes 59400, 59510, 59610, and 59618 describe the global services for routine obstetric care
...
Under certain circumstances, the same physician (solo practice) or same physician group (group practice) does not provide the global maternity care and delivery services
...
Under these circumstances the use of the global codes is not appropriate
...
Codes in the CPT codebook exist for reporting the specific services provided when the global codes are not appropriate
...
Codes 59425 and 59426 are available for reporting antepartum care only
...
Codes 59409, 59514, 59612, and 59620 describe delivery services only
...
Codes 59410, 59515, 59614, and 59622 describe delivery services including postpartum care
...
The provision of postpartum care only is reported with code 59430
...
The following services are not included in the global obstetric package:

Management of inpatient or outpatient medical complications not related to pregnancy, such as cardiac problems, neurologic problems, pneumonia, chronic hypertension, diabetes, etc
...
Management of inpatient or outpatient medical complications related to pregnancy, such as bleeding, preterm labor, pregnancy-induced hypertension, toxemia, hyperemesis, premature rupture of membranes, etc
...
If there are more than 13 outpatient visits or inpatient visits
...
The laboratory tests performed during pregnancy, excluding dipstick urinalysis
...
Routine venipuncture (code 36415)
...
Management of surgical complications and problems of pregnancy, such as incompetent cervix, hernia repair, ovarian cyst, Bartholin cyst, ruptured uterus, appendicitis (reported separately with the appropriate codes from the Surgery section of the CPT codebook [eg, codes 44950, 59320, 59325, 59350])
Amniocentesis, chronic villous sampling, and cordocentesis (reported separately when performed [codes 59000, 59001, 59015, 59012])
Fetal contraction stress test and fetal nonstress test (reported separately when performed [codes 59020, 59025])
Insertion of cervical dilator by physician (eg, laminaria, prostaglandin [code 59200])
External cephalic version with or without tocolysis (code 59412)
The obstetric limited or complete ultrasound (reported separately with codes 76805, 76810, 76815, 76816, 76830)
Fetal biophysical profile (code 76818, 76819)
Fetal echocardiography (codes 76825, 76826, 76827, 76828)
Administration of RH immune globulin (code 90772)

Hospital visits within 24 hours of delivery are generally considered part of the global service
...
2
...
What's included in the global obstetric care?
Cesarean Delivery
Separate codes exist for reporting routine obstetric care associated with cesarean delivery
...
CPT code 59510, Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, reports the global care provided to obstetric patients including those who have had a previous cesarean section delivery and return for elective repeat cesarean section delivery
...
Code 59514 describes cesarean delivery only
...
If postpartum care is also provided by the same physician or physician group, code 59515, Cesarean delivery only
...
including postpartum care, is reported
...
If a subtotal or total hysterectomy is performed after cesarean delivery, code 59525 is reported in addition to the code for primary procedure
...
Codes 59618, 59620, and 59622 can be reported for cesarean deliveries
...
(See Figure 4-101
...
)
FIGURE 4-101 Cesarean Delivery

Abortion
The definition of abortion is the premature expulsion from the uterus of the products of conception, the embryo, or a nonviable fetus
...
Abortions may be categorized as either spontaneous, the natural (with no active interference) termination of pregnancy prior to the 20th week of gestation, or induced, in which a deliberate attempt has been made to terminate the pregnancy
...
Abortion: The premature expulsion from the uterus of the products of conception, the embryo, or a nonviable fetus
...
The different types of abortions that are reportable with CPT codes as follows
...
Threatened Abortion
A threatened abortion is diagnosed when vaginal bleeding occurs in the first 20 weeks of pregnancy
...
The differential diagnosis of this bleeding that occurs in early pregnancy in approximately 20% of all patients is usually included in the antepartum care component of routine obstetric care of the patient who successfully delivers
...
In the event that the patient being treated for a threatened abortion requires additional visits, these should be coded separately using E/M services codes, according to the services the physician provides
...
Spontaneous Abortion (Miscarriage)
Spontaneous abortions are also known as miscarriages
...
The types of spontaneous abortion include:

Complete abortion
Incomplete abortion
Missed abortion
Septic abortion
Blighted ovum
Complete Abortion
...
When a spontaneous abortion that is complete (any trimester) occurs and the physician manages the patient medically with no surgical intervention, the physician should report the appropriate level of E/M code, dependent on the place where the patient is seen (99201-99233)
...
Incomplete Abortion
...
An incomplete abortion occurs when the uterus is not entirely emptied of its contents
...
Fragments of the products of conception may remain within the uterus, may protrude from the external os of the cervix, or can be found in the vagina
...
Some fragments of the products of conception may have spontaneously passed out of the vagina
...
Code 59812, Treatment of incomplete abortion, any trimester, completed surgically, is used to report the dilation and curettage (either sharp or suction curettage) for the surgical management of an incomplete abortion
...
However, if the patient is septic and is diagnosed as experiencing an incomplete abortion, do not use code 59812
...
(See septic abortion
...
)
Missed Abortion
...
A missed abortion refers to the prolonged retention of a fetus that died in the first half of pregnancy
...
The evacuation of the uterus in these cases is coded according to the trimester in which the procedure is performed, ie, 59820, Treatment of missed abortion, completed surgically
...
first trimester, and 59821 for the second trimester
...
Septic Abortion
...
Septic abortions are those in which intrauterine infection is present
...
Most often this infection is confined to the uterus, but peritonitis and septicemia are not rare
...
Treatment of the infection involves, in addition to treatment with antibiotics, the prompt evacuation of the products of conception
...
Code 59830, Treatment of septic abortion, completed surgically, is used to report these services
...
Blighted Ovum
...
The advent of diagnostic tools that aid in the very early detection of pregnancy, such as beta subunit human chorionic gonadotropin (HCG) and ultrasound, has had an impact in defining when early "abortion" occurs
...
The instance of a positive pregnancy test with a blighted ovum identified on ultrasound (a pathologic ovum in which the embryo was degenerated or absent) raises the question of whether a code for treatment of abortion should be selected or a code for dilation and curettage, since there was no (viable) product of conception present
...
In many of these cases, women who did not seek medical attention for early diagnosis of pregnancy would not have previously identified a delayed menstrual cycle as the loss of a pregnancy nor have been aware that any conception had occurred
...
However, if a pregnancy is diagnosed and terminates, either by spontaneous or induced means, the abortion codes should be used to report the physician services related to the abortion
...
Induced Abortion
Both therapeutic and elective abortions may be classified as induced abortions
...
Therapeutic abortion is the termination of pregnancy before the time of fetal viability for medical indications
...
Elective abortion is the interruption of pregnancy before viability at the request of the woman
...
Coding for an induced abortion is done based on the technique used
...
This may be done surgically, by dilating the cervix and performing curettage or using vacuum aspiration
...
Medical induction may be performed by the administration of oxytocin or the administration of prostaglandins
...
Intra-amniotic injections of saline or urea are also used to induce abortions
...
When an induced abortion is performed by dilating the cervix and performing sharp and/or suction curettage, code 59840, Induced abortion, by dilation and curettage, is reported
...
If the cervix is dilated and the uterus mechanically evacuated, code 59841,Induced abortion, by dilation and evacuation, is reported
...
In the event that a small amount of sharp curettage is needed to complete the dilation and evacuation, this is included when reporting 59841
...
Abortions performed during the second trimester are sometimes performed using intra-amniotic hyperosmotic solutions (saline or urea)
...
These solutions are injected to stimulate uterine contractions and cervical dilation to deliver the products of conception
...
This is coded using 59850 and includes admission to a facility, necessary hospital visits, and follow-up care
...
59850
Induced abortion, by one 1 or more intra-amniotic injections (amniocentesis-injections), including hospital admission and visits, delivery of fetus and secundines)
59851
with dilation and curettage and/or evacuation
59852 with hysterotomy (failed intra-amniotic injection)
In the event that the intra-amniotic injections facilitate the evacuation of the uterus but curettage and/or dilation is necessary to complete the procedure, code 59851 is reported
If other methods are not successful or if there are additional indications, an abdominal hysterotomy may be necessary to terminate pregnancy
...
This technique is similar to the technique of cesarean delivery except that the abdomen and uterus are generally smaller
...
In this case, code 59852 is reported and encompasses both the attempted intraamniotic injections as well as the surgical hysterotomy
...
If a laminaria is inserted prior to any of the procedures discussed in this chapter, code 59200, Insertion of cervical dilator (eg, laminaria, prostaglandin) (separate procedure), may also be reported because it is not included as a part of any of the other procedures
...
BOOK II COMPLETE



PRINCIPLES OF CPT CODING
BOOK III

Female Genital System
Codes for reporting procedures of the female genital system are found in the 56405-58999 series
...
Anatomy of the female genital system can be seen in Figure 4-57
...
Specific codes are available for reporting procedures in the following subsections:
Vulva, Perineum, and Introitus (56405-56821)
Vagina (57000-57426))
Cervix Uteri (57452-57800)
Corpus Uteri (58100-58579)
Oviduct/Ovary (58600-58770)
Ovary (58800-58960)
In Vitro Fertilization (58970-58999)
A series of codes also exists for reporting procedures related to laparoscopic and hysteroscopic surgery of the uterus (58541-58579) and laparoscopic surgery related to procedures on the oviduct or ovaries (58660-58679)
...
Code 58999 is available for reporting unlisted (nonobstetrical) procedures of the female genital system
...
(Refer to Chapter 1 for further discussion of unlisted codes
...
)
The separate procedure designation is used throughout the female genital system codes
...
Coders should become familiar with the guidelines associated with reporting codes that have the separate procedure designation
...
(Refer to the guidelines section at the beginning of this chapter
...
)
CODING TIP Codes designated as separate procedures may not be additionally reported when the procedure or service is performed as an integral component of another procedure or service
...
Within each anatomic subsection (Vulva, Perineum, and Introitus
...
Vagina
...
Cervix Uteri
...
Corpus Uteri
...
Oviduct/Ovary
...
and Ovary), there are specific listings for procedures that involve incision, destruction, excision, repair, etc
...
At the beginning of the first anatomic heading, the following definitions that are applicable to the vulvectomy codes (56620-56640) appear:
A simple vulvectomy procedure is the removal of skin and superficial subcutaneous tissues
...
A radical vulvectomy procedure is the removal of skin and deep subcutaneous tissue
...
Removal of less than 80% of the vulvar area is defined as a partial vulvectomy
...
Removal of greater than 80% of the vulvar area is defined as a complete vulvectomy
...
FIGURE 4-57
Female Genital System
When coding for vulvectomy procedures, first determine the extent of the procedure performed from the operative report
If this information is not clearly documented, clarification should be sought before code assignment
...
Codes 56605 and 56606 are used to report biopsy of the vulva or perineum
...
Code 56605 is reported for biopsy of one lesion
...
Biopsy of each separate additional lesion is reported with code 56606
...
Code 56606 is designated as an add-on code
...
This code would never be reported without first reporting code 56605
...
Code 56820 describes endoscopic examination and magnification of the vulva to evaluate for viral lesions, neoplasia, or malignancy
...
Code 56821 is used to report the same service with biopsy(s)
...
If multiple biopsies are performed on the vulva during the same session, then code 56821 is only reported one time, as indicated by the inclusion of the plural form of biopsy
...
Additional endoscopic examinations of other sites are reported separately with modifier 51 appended
...
Within the series of codes for reporting procedures of the vagina (57000-57426), specific listings are given for procedures that involve incision, destruction, excision, introduction, repair, manipulation, and endoscopy/laparoscopy
...
Codes 57022 and 57023 describe incision and drainage of a vaginal hematoma differentiated as a hematoma occurring in an obstetrical patient as a result of delivery (57022) or a nonobstetrical condition resulting from trauma or injury (57023)
...
An injury resulting in a vaginal hematoma that occurs in a pregnant woman who sustains an injury before and unrelated to delivery (eg, bicycle mishap) is reported with code 57023
...
Codes 57061 and 57065 are used to report destruction of vaginal lesion(s) by any method
...
Code 57061 is used to report a simple destruction procedure
...
Code 57065 is used to report an extensive destruction procedure
...
The methods or techniques of destruction listed in codes 57061 and 57065 include but are not limited to laser surgery, electrosurgery, cryosurgery, and chemosurgery
...
CODING TIP HCPCS Level II code A4261 may be used instead of CPT code 99070 to report the supply of a cervical cap for contraceptive use
...
The introduction codes in this anatomic site include diaphragm or cervical cap fitting (57170), fitting and insertion of a pessary or an intravaginal support device (57160), and introduction or irrigation of medication or hemostatic agents into the vagina for injuries or infection (57150 and 57180)
...
Also, code 57155 is available for insertion of a single tandem (hollow cylinder) and/ or a vaginal ovoid (empty capsule into which a radioactive element can be placed) in preparation for radiation therapy (brachytherapy) for cervical cancer
...
For insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy, report code 57156
...
The actual insertion of the radioactive element and radiation therapy is performed by the radiologist, and a series of codes is included in the Radiology section under the Clinical Brachytherapy subsection (77761-77763, 77785-77787) to report these procedures
...
CODING TIP For placement of needles or catheters into pelvic organs and/or genitalia (except prostate) for interstitial radioelement application, code 55920 is reported
...
The repair codes pertaining to the vagina include vaginal and perineal injuries not occurring during delivery (57200-57210), vaginal repairs involving urinary and rectal structures (57220-57260), repair of vaginal hernias (57265-57270), correction of vaginal prolapse and stress urinary incontinence (57282-57288), closure of rectovaginal and urethrovaginal fistulas (57300-57330), and construction of artificial vagina (57291, 57292)
...
Laparoscopic colpopexy is reported with code 57425
...
Open colpopexy procedure codes should never be used when the laparoscopic approach is performed
...
If mesh or other prosthesis is used when a vaginal repair is performed, then it would be appropriate to report add-on code 57267
...
CODING TIP It is not appropriate to report the "open" procedure code to report a procedure performed laparoscopically
...
CODING TIP Code 57283, Colpopexy, vaginal
...
intraperitoneal approach (uterosacral, levator myorrhaphy) is not used in conjunction with codes 58263, 57556, 58270, 58280, 58292, and 58294
...
Also, it should be noted that some of the code descriptors for listings in the repair series of codes include the parenthetical note "nonobstetrical"
...
If these procedures are performed as an obstetric procedure, then the appropriate code from the Maternity Care and Delivery subsection is used to report the procedure
...
CODING TIP Code 57284, Paravaginal defect repair (including repair of cystocele, if performed)
...
open abdominal approach, should not be used in conjunction with codes 51840, 51841, 51990, 57240, 57260, 57265, 58152, and 58267
...
The codes under the Manipulation heading include codes to report pelvic examination (57410), dilation of vagina (57400), and removal of impacted vaginal foreign body (57415) performed under anesthesia other than local
...
A pelvic examination performed with a local anesthetic or without anesthesia is not reported separately
...
it is included in the level of E/M service reported for the visit
...
(Refer to Chapter 2 for further discussion of E/M coding
...
) Similarly, removal of impacted foreign body performed without anesthesia is included in the level of E/M service for the visit
...
Under the Endoscopy/Laparoscopy heading, codes 57420 and 57421 are used to report endoscopic examination and magnification of the surface of the vagina, performed for those patients with conditions that include abnormal Pap smear or prior hysterectomy with cervix removal and abnormal Pap smear
...
Examination of contiguous portions of the cervix performed as a part of the endoscopic vaginal examination are included and not separately reported
...
Codes 57423-57426 are used to report laparoscopic procedures
...
Code 57423 is reported for laparoscopic paravaginal defect repair and includes the repair of cystocele when performed
...
Code 57425 is reported for laparoscopic colpopexy (suspension of vaginal apex)
...
Code 57426 is used to report laparoscopic revision of prosthetic vaginal graft necessary due to infection
...
This code includes the removal of a prosthetic vaginal graft, when performed
...
Codes 57452-57461 are used to report cervical colposcopic procedures
...
Code 57452 describes a diagnostic colposcopic examination of the cervix and the upper/adjacent vagina
...
Code 57454 is used to report colposcopy with biopsy(s) of the cervix and endocervical curettage
...
Because the descriptor includes both the singular and plural form of biopsy, this code is reported only one time, whether one or multiple cervical biopsies are performed
...
If only a biopsy of the cervix is performed, it would be appropriate to report code 57455
...
If only endocervical curettage is performed, it would be appropriate to report code 57456
...
Codes 57454-57461 are further differentiated according to the biopsy method (ie, excisional, loop electrode)
...
CODING TIP For endometrial biopsy performed with culposcopy, report code 58110 in addition to the colposcopy code
...
Code 57460 is used to report loop electrode biopsy(s) procedure of the cervix performed at the same operative episode as a colposcopy
...
In this procedure, the vagina and cervix are viewed through a colposcope
...
A hot cautery wire is used to excise a cone or section of cervical tissue and cauterize the area at the same time
...
The loop electrode conization procedure, described by code 57461, consists of a procedure performed to obtain a large tissue specimen from patients with abnormal Pap smears in which a portion of the endocervix (most typically in the transformation zone) is excised where a discrete lesion has been visualized on the exocervix
...
It typically involves use of a loop electrode to excise a lesion on the ectocervix with adequate margins and subsequent use of a second loop to remove the involved portion of the endocervix
...
Code 57461 is not reported in addition to code 57456, as the endocervical curettage reported by code 57456 is an inclusive component of the loop electrode conization
...
FIGURE 4-58
Endometrial Sampling (Biopsy) With or Without Endocervical Sampling (Biopsy)
Within the cervix uteri series of codes (57452-57800), subcategories of codes can be found for endoscopy, excision, repair, and manipulation
Code 57520 is used to report excision of a cone shape of endocervical tissue (conization) of the cervix by means of a cold knife or laser without a colposcopy
...
When this code is reported, any fulguration, dilation and curettage (D&C), or repair performed is also included and not reported separately
...
FIGURE 4-59
Total Abdominal Hysterectomy, With or Without Removal of Tube(s), With or Without Removal of Ovary(s)

FIGURE 4-60
Vaginal Hysterectomy, With Total or Partial Vaginectomy
With Repair of Enterocele
Code 57522 is used to report the excision of a cone shape of endocervical tissue by means of a loop electrode
...
Because a conization of the cervix by the loop electrode procedure is a different, less complex procedure than conization with cold knife or laser, separate codes are listed to differentiate between these techniques
...
If a loop electrode biopsy is performed with a colposcopy, code 57460 is reported
...
Colposcopic loop electrode conization is reported with code 57461
...
Codes in the corpus uteri series (58100-58579) are used to report procedures involving excision, introduction, repair, laparoscopy, and hysteroscopy
...
(See Figure 4-58
...
)
Codes 58140-58146 open vaginal and abdominal approach procedures for excision of intramural myomas (uterine fibroids)
...
The myomectomy codes are further differentiated by the total weight of the excised lesions
...
A myomectomy performed laparoscopically is reported with codes 58545-58546
...
Various hysterectomy procedures are included in this subsection
...
Code 58150 is used to report a total abdominal hysterectomy, with or without removal of tube(s), with or without removal of ovary(s)
...
(See Figure 4-59
...
) Codes in the 58260-58294 series are used to report vaginal hysterectomy procedures
...
Removal of the fallopian tube(s) and/or ovary(s), when performed with an abdominal hysterectomy procedure, is not reported separately
...
The code descriptors for abdominal hysterectomy procedures include the language "with or without removal of tube(s), with or without removal of ovary(s)
...
" If a salpingectomy (58700), salpingooophorectomy (58720), or oophorectomy (58940) is performed as a separate procedure without an abdominal or vaginal hysterectomy, then codes 58700, 58720, and 58940 are used, as appropriate, to report these procedures
...
In addition, if an enterocele or urethrocystopexy repair is performed at the same session as a vaginal hysterectomy procedure, it should be determined whether the appropriate codes in the 58260-58294 series are available before referring to procedures from the 57200-57330 series of codes
...
(See Figure 4-60
...
)
The introduction codes within the corpus uteri series include insertion and removal of intrauterine devices (IUDs) (58300-58301) and introduction of catheters for diagnostic purposes (eg, hysterosalpingography, hysterosonography) or to establish patency of fallopian tubes (58340 and 58345)
...
The radiological component of these two procedures is listed in the Radiology section of the CPT code set and includes codes 76831, 74740, and 74742
...
Several codes also exist within this anatomical heading related to fertility medicine, including artificial insemination (58321, 58322) and sperm washing for artificial insemination (58323)
...
The remainder of the codes under Introduction include chromotubation of oviduct (58350), insertion of Heyman capsules for clinical brachytherapy (58346), thermal endometrial ablation (58353), and endometrial cryoablation with ultrasonic guidance (58356)
...
Code 58353 involves insertion of a balloon catheter through the vagina into the uterus and inflation of the balloon, which can be heated to a high temperature to ablate the benign tissue associated with benign menorrhagia (eg, dysfunctional uterine bleeding)
...
A similar procedure, which involves the use of a hysteroscope, reported as code 58563, utilizes an electrode loop, roller ball, or laser to ablate the tissue
...
The laparoscopy codes in this section are reported for supracervical hysterectomy, myomectomy, and vaginal hysterectomy procedures differentiated by size (> 250 g or ≤ 250 g uterus) and inclusion of the salpingo-oophorectomy procedure
...
Codes 58541-58544 and 58548 are used to report various laparoscopic hysterectomy procedures
...
Codes 58541-58544 describe laparoscopic supracervical hysterectomy
...
The instructional parenthetical notes following codes 58542 and 58544 clarify that codes 58541-58544 should not be reported in addition to codes 49320, 57000, 57180, 57410, 58140-58146, 58545, 58546, 58561, 58661, 58670, or 58671
...
Code 58548 is used to report laparoscopic radical hysterectomy with bilateral total pelvic lymphadenectomy and paraaortic lymph node sampling
...
This code includes the removal of tubes and ovaries, if performed
...
An instructional parenthetical note following code 58548 clarifies that laparoscopic retroperitoneal lymph node biopsy (38570-38572), radical abdominal hysterectomy (58210), radical vaginal hysterectomy (58285), and laparoscopic vaginal hysterectomy (58550-58554) are all inclusive components of laparoscopic radical hysterectomy and should not be reported separately with code 58548
...
Also, codes 58550-58552 should not be reported in conjunction with 49320, 57000, 57140, 57180, 58140-58146, 58545, 58546, 58561, 58661, 58670, or 58671
...
In addition to the procedure (58563) listed previously, many other procedures can be performed with the use of a hysteroscope, including code 58558, which describes surgical hysteroscopy with sampling (biopsy) of the endometrium and/ or polypectomy, with or without a D&C
...
A D&C is commonly performed with a hysteroscopy
...
thus, both of these procedures are reported using a single code
...
The code is worded in this way to make it clear that when sampling (biopsy or curetting) of the endometrium and/or polypectomy is performed, the D&C should not be coded separately
...
Additionally, because a biopsy sample can be obtained by a D&C, the code also represents a hysteroscopy with biopsy
...
Two unlisted procedure codes are included within the Uterus series of codes to report unlisted laparoscopy (58578) and hysteroscopy (58579) procedures
...
(Refer to Chapter 8 for further discussion of unlisted codes
...
)
Codes 58570-58573 are used to report the laparoscopic procedure for a total hysterectomy, for a uterus less than or equal to or more than 250 g
...
with or without the removal of tube(s) and/ or ovary(s)
...
The parenthetical note for this series states codes 58570-58573 should not be used in conjunction with codes 49320, 57000, 57180, 57410, 58140-58146, 58150, 58545, 58546, 58561, 58661, 58670, and 58671
...
CODING TIP The use of modifier 50 with any of the tubal ligation or transection procedure codes is not appropriate
...
The codes descriptors indicate unilateral or bilateral procedures
...
Within the series of codes describing procedures of the oviduct and ovary (58600-58770), codes are available for reporting ligation or transection of fallopian tube(s) (tubal ligation) and occlusion of fallopian tube(s) by device
...
Following is a review of the various codes for reporting these procedures
...
Code 58600 is used to report tubal ligation or transection via abdominal or vaginal approach
...
This code is appropriate for reporting either a unilateral or a bilateral procedure
...
This code is not appropriate if the procedure is performed during the postpartum period during the same hospitalization as the delivery (see code 58605)
...
Also, this code is not used to report tubal ligation or transection when done at the time of a cesarean delivery or intra-abdominal surgery (see code 58611)
...
Code 58605 describes a postpartum tubal ligation or transection performed during the same hospitalization as the delivery
...
This code is appropriate for procedures performed via either an abdominal or a vaginal approach, with unilateral or bilateral tubal ligation or transection
...
This code should not be reported for tubal ligation or transection performed at the time of cesarean delivery or intra-abdominal surgery (see code 58611)
...
This code is designated as a separate procedure
...
Code 58611 is an add-on code that is used to report tubal ligation or transection when done at the time of cesarean delivery or intra-abdominal surgery (during the same operative session)
...
This code is to be reported separately, in addition to the code for the cesarean delivery or intra-abdominal surgery performed
...
This code should not be reported if the tubal ligation or transection is performed at a separate operative session from the cesarean delivery or intraabdominal surgery (see code 58600 or 58605, as appropriate)
...
The occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) is reported with code 58615
...
This code is appropriate whether a vaginal or a suprapubic approach is employed
...
Laparoscopic procedures for fulguration or occlusion of oviducts are reported with codes 58670 and 58671
...
Code 58670 is used to report laparoscopic fulguration of oviducts (with or without transection), and code 58671 is used to report laparoscopy with occlusion of oviducts by device (eg, band, clip, or Falope ring)
...
The excision and repair listing of the oviduct/ ovary series of codes following the laparoscopy procedures describes open procedures without the use of a laparoscope
...
Codes 58700 and 58720 are used to report the partial or complete excisional removal of the fallopian tubes (58700) and the fallopian tubes with removal of the ovaries (58720)
...
These two codes should not be reported when the procedures are performed as part of a more major procedure (eg, hysterectomy, pelvic exenteration) (see previous discussion of codes in the Corpus Uteri subsection)
...
Codes 58740-58770 are used to report procedures related to the repair of the fallopian tubes, including anastomosis procedures (58740, 58750, 58752, 58770), and lysis of adhesions occurring within the fallopian tubes or ovary(s)
...
The 58800-58960 series of codes is used to report procedures involving primarily the ovary(s), including biopsy (58900), resection (58920, 58950-58952), cyst removal (58925), and partial or total removal (58940) in cases of ovarian, tubal, or primary peritoneal malignancy
...
These codes describe both unilateral and bilateral procedures
...
Codes 58943 and 58950-58952 are reported for procedures involving the ovary(s) and other adnexal structures, including a total abdominal hysterectomy (58951) in cases of ovarian, tubal, or primary peritoneal malignancy
...
Code 58960 is used to report a staging or restaging procedure for ovarian, tubal, or peritoneal malignancies
...
Fitting and Insertion of Pessary
The fitting and insertion of a pessary or other intravaginal support device is reported with code 57160
...
The supply of the pessary is not included when code 57160 is reported
...
It is appropriate to separately report the supply item with CPT code 99070 or the appropriate HCPCS Level II code
...
CODING TIP HCPCS Level II code A4561 (rubber) or A4562 (nonrubber) may be used instead of CPT code 99070 to report the supply of a pessary
...
Diaphragm or Cervical Cap Fitting
Diaphragm or cervical cap fitting is reported with CPT code 57170
...
As indicated in the code descriptor, instructions to the patient regarding the use of the diaphragm or cervical cap are included when this code is reported
...
The supply of the diaphragm or cervical cap is not included when code 57170 is reported
...
The supply item is separately reported with CPT code 99070 or the appropriate HCPCS Level II code
...
Insertion and Removal of an IUD
CPT code 58300 is used to report the insertion of an IUD
...
This code is intended to be used to report only the insertion of an IUD
...
It does not include the supply of the IUD itself
...
CPT code 99070 or the appropriate HCPCS Level II code is reported separately to report the supply of the IUD
...
CODING TIP HCPCS Level II code J7300 is used to report the supply of an intrauterine copper contraceptive
...
This code may be used instead of CPT code 99070 for the supply of an IUD
...
CODING TIP Codes 11980, 11981, and 11976 are used to report the introduction of drug delivery implants
...
Code 11980 is for the subcutaneous hormone implantation of estradiol and/or testosterone pellets beneath the skin
...
Removal of implantable contraceptive capsules is reported with code 11976
...
Code 11981 is used to report the insertion of non-biodegradable drug delivery implant for contraception
...
To report the removal of implantable contraceptive capsules with subsequent insertion of non-biodegradable drug delivery implant use 11976 In addition to 11981
...
Maternity Care and Delivery
Following is a review of the listings for maternity care and delivery procedures
...
The codes for amniocentesis (59000), cordocentesis (59012), and chorionic villus sampling (59015) are used to report only the procedural portion of the service
...
The radiological S&I are reported separately with the appropriate 70000 series code from the Radiology section of the CPT codebook
...
(Refer to Chapter 5 for more on radiological S&I
...
)
Codes 59050 and 59051, used to report fetal monitoring during labor, are reported only when the service is performed by a consulting physician or other qualified health care professional (ie, nonattending)
...
Code 59050 is used to report the S&I of the monitoring, and code 59051 is reported when the only service provided is the interpretation of the fetal monitoring
...
This service is not reported separately when provided by the attending
...
Codes 59070-59076 are used to report intrauterine fetal surgical procedures, including ultrasound guidance
...
Ultrasound guidance is not separately reported
...
Code 59074 describes a procedure in which a needle is inserted into an organ to aspirate fluid
...
Code 59076 is used to report fluid drainage using a fetal shunt, which allows for continuous drainage of excessive fluid such as in the instances of hydronephrosis or hydrothorax
...
Fetal invasive procedures that are not listed in this series are reported with code 59897
...
when performed, ultrasound guidance is included
...
FIGURE 4-61
Laparoscopic Treatment of Ectopic Pregnancy
With Salpingectomy and/or Oophorectomy
Codes for surgical treatment of an ectopic pregnancy are found in the 59120-59151 series
...
The appropriate code is selected on the basis of the site of the ectopic pregnancy and the specific procedure performed
...
Codes 59150 and 59151 are used to report laparoscopic treatment of an ectopic pregnancy
...
(See Figure 4-61
...
) The appropriate code is selected according to whether the laparoscopic treatment was performed with salpingectomy and/or oophorectomy (59151) or without salpingectomy and/or oophorectomy (59150)
...
Episiotomy or vaginal repair performed by an individual other than the attending is reported with code 59300
...
When episiotomy or vaginal repair is performed by the attending, this service is not reported separately, as it is included in the code reported for the vaginal delivery
...
For CPT nomenclature coding purposes, small vaginal tears are not considered a complication of the delivery
...
If minor vaginal tearing occurs and the repair is minimal, it would be considered management of uncomplicated labor and delivery and not be reported separately
...
If, however, an extensive laceration occurs, modifier 22, Increased procedural services, may be appended to the code reported for the vaginal delivery to identify the additional effort involved in the repair
...
(Refer to Chapter 8 for further discussion of modifier 22
...
)
CODING TIP Induction of labor with oxytocin is an inclusive component of the obstetric package or the delivery
...
No additional code is reported for the induction of labor
...
Cerclage of the cervix during pregnancy is reported with codes 59320 and 59325
...
The appropriate code is selected on the basis of the approach used to perform the procedure
...
Code 59320 is used to report a vaginal approach, and code 59325 an abdominal approach
...
Subsequent removal of cerclage sutures at the time of delivery is considered part of the delivery and are not reported separately
...
However, removal of the cerclage suture under anesthesia before the onset of labor, or at a time that extends beyond the global period of the placement procedure, is reported separately with code 59871, provided the removal is performed under anesthesia (other than local)
...
The next sections focus on the various code series and associated guidelines for reporting services normally provided in uncomplicated maternity cases
...
CODING TIP Vacuum extraction during a vaginal delivery is considered an inherent part of the delivery service(s) provided
...
There is no separate procedure code assignment for vacuum extraction delivery of the fetus
...
The ICD-9-CM diagnosis code(s) reported should reflect the need for vacuum extraction delivery
...
The Obstetric Package
The services normally provided in uncomplicated maternity cases include routine antepartum care, delivery, and postpartum care
...
This is the global package for maternity care and delivery
...
The guidelines at the beginning of the Maternity Care and Delivery subsection define the services included when antepartum care, delivery services, and postpartum care are reported
...
Antepartum care includes the following:
The initial and subsequent history
Physical examinations
Recording of weight, blood pressures, and fetal heart tones
Routine chemical urinalysis
Monthly visits up to 28 weeks' gestation, biweekly visits to 36 weeks' gestation, and weekly visits until delivery
The E/M services (visits) provided with those services included in the provision of antepartum care are not separately reported
...
However, any other visits or services provided within the antepartum period other than those listed previously are reported separately
...
Medical complications of pregnancy (eg, cardiac problems, neurological problems, diabetes, hypertension, toxemia, hyperemesis, preterm labor, premature rupture of membranes, trauma) and other medical problems complicating labor and delivery management may require the provision of additional E/M services and/or services described in the Medicine section of the CPT codebook
...
When additional services are required beyond those specified in the Maternity Care and Delivery guidelines, those services are reported separately in addition to the codes for maternity care
...
CODING TIP Artificial rupture of membranes before delivery is an inclusive component of the delivery code reported and not separately reported
...
For surgical complications of pregnancy (eg, appendectomy, hernia repair, ovarian cyst, Bartholin cyst), the appropriate code(s) from the Surgery section of the CPT codebook is reported in addition to the codes for maternity care and delivery
...
Delivery services include the following:
Admission to the hospital
The admission history and physical examination
Management of uncomplicated labor
Vaginal delivery (with or without episiotomy, with or without forceps) or cesarean delivery
Delivery of the placenta is considered to be an integral component of the total vaginal or cesarean delivery
...
Therefore, code 59414 is not reported in addition to the code for the delivery service
...
Code 59414 is appropriately reported for the delivery of placenta in situations in which the patient delivers vaginally before admission with subsequent delivery of the placenta by a physician or other qualified health care professional
...
Postpartum care includes hospital and office visits following vaginal or cesarean delivery
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CODING TIP Hospital visits within 24 hours of delivery are generally part of the global service
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Following is a review of the codes available for reporting routine obstetric care
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Separate codes exist for reporting routine obstetric care associated with the following:
Vaginal delivery
Cesarean delivery
Delivery after previous cesarean delivery
Global Services for Routine Obstetric Care
When the same physician (solo practice) or same physician group (group practice) provides the global routine obstetric care (including antepartum care, delivery, and postpartum care), the appropriate global code is reported for the services rendered
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Codes 59400, 59510, 59610, and 59618 describe the global services for routine obstetric care
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Following is a review of the differences among these code descriptors
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Code 59400 is used to report routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy and/or forceps, vacuum), and postpartum care
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Code 59510 is used to report routine obstetric care including antepartum care, cesarean delivery, and postpartum care
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This code is also used to report global care provided to patients who have had a previous cesarean delivery and return for elective repeat cesarean delivery
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Code 59610 describes the global care associated with vaginal birth after previous cesarean delivery
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Included when this code is reported are antepartum care, vaginal delivery (with or without episiotomy and/or forceps), and postpartum care for a patient who has had a previous cesarean delivery
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Code 59618 is used to report the global care associated with cesarean delivery after attempted vaginal delivery after previous cesarean
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If the attempt to deliver vaginally after a previous cesarean delivery is unsuccessful and another cesarean delivery is performed, then code 59618 is used to report the global service
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All the codes for vaginal delivery include the parenthetical note "with or without episiotomy and/or forceps
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" No separate reporting occurs for the performance of an episiotomy and/or the use of forceps during delivery
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Also, when performed by the attending, the subsequent repair of the episiotomy is an inclusive component of the delivery service
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As mentioned earlier, code 59300 is used to report episiotomy repair by other than the attending
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Under certain circumstances, the same physician or other qualified health care professional or same group practice does not provide the global maternity care and delivery services
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Under these circumstances, the use of the global codes is not appropriate
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Codes in the CPT nomenclature exist for reporting the specific services provided when the global codes are not appropriate
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When the global care is not provided by the same physician or other qualified health care professinal or same group practice, the following codes and guidelines apply
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Codes 59409, 59514, 59612, and 59620 describe delivery services only
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Codes 59410, 59515, 59614, and 59622 describe delivery services including postpartum care
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The following paragraphs highlight the differences among these code descriptors
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Code 59409 is used to report vaginal delivery only (with or without episiotomy and/or forceps)
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If the postpartum care is also provided by the same physician or other qualified health care professional or the same group practice, then code 59410 is reported
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These codes are not used to report vaginal delivery after a previous cesarean delivery (see codes 59610-59612)
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Code 59514 is used to report cesarean delivery only
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If the postpartum care is also provided by the same physician or same physician group, then code 59515 is reported
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Code 59612 is used to report vaginal delivery only (with or without episiotomy and/or forceps) after a previous cesarean delivery
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If the postpartum care is also provided by the same physician or other qualified health care professional or the same group practice, then code 59614 is reported
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Code 59620 describes an attempted vaginal delivery following a previous cesarean delivery that results in another cesarean delivery
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If the postpartum care is also provided by the same physician or the same physician group, then code 59622 is reported
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Codes 59425 and 59426 are available for reporting antepartum care only
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If 4 to 6 antepartum visits are provided, then code 59425 is reported
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Seven or more antepartum visits are reported with code 59426
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If the physician or other qualified health care professional provides 1 to 3 antepartum visits, they are individually reported with the appropriate E/M codes
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When filling out the units box on the claim form, the coder should indicate that "1" unit of service was provided when reporting code 59425 or 59426
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The provision of outpatient postpartum care only is reported with code 59430
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If the global care is provided by the same physician or other qualified health care professional or the same group practice, the appropriate global code is reported
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Under these circumstances, it is not appropriate to separately report the antepartum, delivery, and postpartum care
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Following are a few examples of when it would be appropriate to separately report the provision of antepartum, delivery, and postpartum care
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EXAMPLE 1
Termination of pregnancy: A patient is seen for three antepartum visits and then experiences a miscarriage (abortion)
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the entire global maternity care service was not provided
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In this case, each of the three visits is coded as an E/M service on the basis of the services provided
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If the patient is new to the physician or other qualified health care professional, a new patient office or other outpatient services code (99201-99205) would be chosen for the initial visit
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codes from the established patient office or other outpatient services code (99211-99215) would be reported for the next two visits
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If the patient is not new to the physician or other qualified health care professional, the appropriate level of E/M service from the established patient office or other outpatient services codes would be reported for the initial and subsequent visits
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(Refer to Chapter 2 for further discussion on appropriate selection of a level of E/M service
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)
EXAMPLE 2
Relocation of the patient: Dr A provided Mrs Adams with 8 antepartum visits before she relocated from Illinois to Texas
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After her arrival in Texas, Mrs Adams resumed her prenatal care with Dr B
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Dr B provided a total of 5 antepartum visits
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In addition, she performed a vaginal delivery and provided all postpartum care
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No complications occurred during maternity care and delivery
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In this example, Dr A reports code 59426 for the antepartum care he provided
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Dr B reports code 59425 for the antepartum care she provided, in addition to code 59410 for the vaginal delivery and postpartum care
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CODING TIP If the physician or other qualified health care professional assists in a cesarean delivery but provides none of the antepartum or postpartum services, a code for global obstetric care is not used
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Instead, the appropriate code for the delivery only is reported, and modifier 80 is appended to denote the surgical assistant services provided
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EXAMPLE 3
Cesarean delivery by another physician: Mrs Kay sees Dr C for her entire pregnancy
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While in labor, Mrs Kay develops a complication that requires the performance of a cesarean delivery
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Dr D assists Dr C with the cesarean delivery
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After delivery, Dr C provides Mrs Kay's postpartum care
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In this example, Dr C reports code 59510 for his services
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Dr D reports code 59514 80
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Modifier 80, Assistant surgeon, is appended to the cesarean delivery only code to indicate Dr D's services as assistant surgeon for the cesarean delivery
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Coding for Delivery of Twins
Coding for the delivery of twins requires careful consideration of the specific services provided
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It should be recognized that third-party payer reporting requirements in these circumstances may vary from CPT coding guidelines
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The coder should become familiar with coding guidelines as well as payer requirements
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The preferred method of reporting vaginal delivery of twins, when the global obstetric care is provided by the same physician or other qualified health care professional or same group practice, is with code 59400 or 59610, as appropriate, with modifier 22, Increased procedural service, appended
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However, in some areas, an alternative reporting method is to use the global code for the delivery of the first twin (code 59400 or 59610, as appropriate) and report the vaginal delivery only code (code 59409 or 59612, as appropriate) for the second twin with modifier 51, Multiple procedures, appended
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(Refer to Chapter 8 for further discussion of modifier 51
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)
If one twin is delivered vaginally and the other by cesarean delivery, and the global obstetric care is provided by the same physician or other qualified health care professional or the same group practice, then the global code (code 59510 or 59618, as appropriate) is reported for the cesarean delivery and the vaginal delivery only code (code 59409 or 59612) with modifier 59, Distinct procedural service, appended to the vaginal delivery code
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If both twins are delivered by cesarean delivery, the appropriate cesarean code is reported, appended by modifier 22
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Coding for Treatment of Abortions
The definition of abortion is the premature expulsion from the uterus of the products of conception, the embryo, or a nonviable fetus
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However, for the layperson, the coding or labeling of a medical record or report as "spontaneous abortion" may be somewhat problematic
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The CPT codes properly use the medical term abortion
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Appropriate coding for the treatment of abortions requires an understanding of how various types of abortions are defined
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Next will be a review of the definitions of the various types of abortions and the related CPT codes
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On the basis of the cause, abortions may be categorized as either spontaneous or induced
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A spontaneous abortion is the natural (with no active interference) termination of pregnancy before 20 weeks, 0 days of gestation
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An induced abortion is one in which a deliberate attempt has been made to terminate the pregnancy
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A threatened abortion is diagnosed when vaginal bleeding occurs in the first 20 weeks of pregnancy
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The differential diagnosis of this bleeding that occurs in early pregnancy in approximately 20% of all patients is usually included in the antepartum care component of "routine" obstetric care of the patient who successfully delivers
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In the event that the patient being treated for a threatened abortion requires additional visits, these are reported separately by means of E/M codes, according to the services provided by the physician
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Following is a review of the terms used in the CPT nomenclature and their definitions as well as the various codes available for reporting the treatment of spontaneous abortions
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Spontaneous Abortion (Miscarriage)
The types of spontaneous abortion include:
Complete abortion
Incomplete abortion
Missed abortion
Septic abortion
Blighted ovum
When a spontaneous abortion that is complete (the uterus is entirely emptied of its contents) occurs (any trimester), and the physician manages the patient medically with no surgical intervention, the physician reports the appropriate level of E/M code
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The category of E/M service is selected on the basis of the place where the patient is seen (eg, physician office, hospital, emergency department)
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An incomplete abortion occurs when the uterus is not entirely emptied of its contents
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Fragments of the products of conception may remain within the uterus, protrude from the external os of the cervix, or remain in the vagina
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Some fragments of the products of conception may have spontaneously passed out of the vagina
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CPT code 59812 is used to report the D&C (either sharp or suction curettage) for the surgical management of an incomplete abortion
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However, if the patient is septic and is diagnosed as having an incomplete abortion, code 59812 is not used
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(See the following paragraph on septic abortion
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)
A missed abortion refers to the prolonged retention of a fetus that died in the first half of pregnancy
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The evacuation of the uterus in these cases is coded according to the trimester in which the procedure is performed
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Code 59820 is reported for procedures performed in the first trimester
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Code 59821 is reported for procedures performed in the second trimester
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Septic abortions are those in which intrauterine infection is present
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Most often this infection is confined to the uterus, but peritonitis and septicemia may occur
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Treatment of the infection involves, in addition to treatment with antibiotics, the prompt evacuation of the products of conception
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Code 59830 is used to report these services
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A blighted ovum is a fertilized egg that fails to develop
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There have been advances of diagnostic tools that aid in the very early detection of pregnancy, such as beta-subunit human chorionic gonadotropin (HCG) and ultrasound
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To positively diagnose a blighted ovum, there must be a positive pregnancy test and a blighted ovum (a pathologic ovum in which there is a degenerated or absent embryo) identified on an ultrasound
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Before the use of ultrasound and beta-subunit HCG testing, a blighted ovum may have gone undetected and was not considered a form of early abortion
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Today, because it is possible to detect pregnancy at a very early stage (several days after conception), a blighted ovum diagnosis is more common
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In the instance of a positive pregnancy test with a blighted ovum identified on ultrasound, questions arise regarding appropriate code assignment for the treatment of a blighted ovum
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Because no (viable) product of conception is present, should a code for treatment of abortion be selected or a code for nonobstetric D&C?
A blighted ovum is a fertilized egg and is considered obstetric rather than nonobstetric
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If a pregnancy is diagnosed and terminates by either spontaneous or induced means, the abortion codes are used to report the physician services related to the abortion
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A blighted ovum may result in one of the following treatments:
Complete spontaneous abortion: In this case, the physician manages the patient medically with no surgical intervention
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The physician reports his or her service by using the appropriate level of E/M code, based on where the service is provided
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Incomplete abortion: In this case, the uterus is not entirely emptied of the products of conception
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The tissue may be found in the uterus, cervix, or vagina
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The physician performs a D&C to remove all remaining tissue for the surgical management of an incomplete abortion
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This is reported with code 59812
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Missed abortion: A missed abortion refers to the prolonged retention of an embryo or fetus that died in the first half of pregnancy
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The evacuation of the uterus in these cases is reported using code 59820 or 59821, based on the trimester in which the procedure is performed
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When the treatment of a blighted ovum is reported, the use of CPT code 58120, Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical), is not appropriate
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As stated previously, a blighted ovum is a fertilized egg and is considered obstetric rather than nonobstetric
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Induced Abortion
Both therapeutic and elective abortions may be classified as induced abortions
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Therapeutic abortion is the termination of pregnancy before the time of fetal viability for medical indications
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Elective abortion is the interruption of pregnancy before viability at the request of the woman
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Coding for an induced abortion is based on the technique used
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This may be done surgically by dilating the cervix and performing curettage or using vacuum aspiration
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Medical induction may be performed by the administration of oxytocin or prostaglandins
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Intra-amniotic injections of saline or urea are also used to induce abortions
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When an induced abortion is performed by dilating the cervix and performing sharp and/or suction curettage, code 59840 is reported
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If the cervix is dilated and the uterus mechanically evacuated, code 59841 is reported
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In the event that a small amount of sharp curettage is needed to complete the dilation and evacuation, this is included when code 59841 is reported
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Abortions performed during the second trimester are sometimes performed with intra-amniotic hyperosmotic solutions (saline or urea)
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These solutions are injected to stimulate uterine contractions and cervical dilation to deliver the products of conception
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This is reported with code 59850
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As indicated in the code descriptor, admission to a facility, necessary hospital visits, and follow-up care are included when this code is reported
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In the event that the intra-amniotic injections facilitate the evacuation of the uterus but curettage and/or dilation is necessary to complete the procedure, code 59851 is reported
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If other methods are not successful or if there are additional indications, an abdominal hysterotomy may be necessary to terminate pregnancy
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This technique is similar to the technique of cesarean delivery except that the abdomen and uterus are generally smaller
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In this case, code 59852 is reported and encompasses both the attempted intra-amniotic injections and the surgical hysterotomy
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BOOK III COMPLETED
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