AHA Coding Clinic® for HCPCS - 2021 Quarter 4; Ask the Editor
Hysteroscopic removal of products of conception (POC)
A patient was given misoprostol for a medication abortion. A few days later, it appeared the abortion was complete. However, due to ongoing bleeding and the suspicion for retained products of conception (POC), the decision was made to proceed with surgical management via ultrasound suction dilation and curettage (D&C) with operative hysteroscopy. A speculum was placed in the vagina and the anterior lip of the cervix was grasped with a tenaculum. Under ultrasound guidance, the uterus was dilated and a flexible suction curette was utilized followed by sharp curettage. A nodule of calcified material consistent with residual POC in the right fundal area was visualized in the ultrasound leading to the decision to proceed with hysteroscopy. The hysteroscope was inserted and the nodule was detached from the endometrium and evacuated from the uterus. When retained POC are treated surgically with hysteroscopy, is it appropriate to report CPT code 59812 or 58558 ? ...
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Article Overview
This Find-A-Code article reviews a gynecologic coding scenario involving suspected retained products of conception after a medication abortion and subsequent surgical management with ultrasound guidance and hysteroscopy. It is intended for coders and billing professionals who need to understand the scope of the procedure discussed, the relevant CPT framework, and the coding question raised by the case.
Why This Topic Matters
Accurate reporting of postpartum or post-abortion surgical services depends on understanding the procedure performed and the coding context. This article helps readers evaluate whether a hysteroscopic approach falls within the same coding considerations as other procedures for retained products of conception.
What You Will Learn
- The clinical context of retained products of conception after medication abortion
- How hysteroscopy fits into the overall surgical management scenario
- The coding question raised by the procedure documentation
- How the article frames CPT reporting considerations for this gynecologic service
Who Should Read This
- Medical coders
- Billers
- OB-GYN coding staff
- Revenue cycle professionals
Codes Discussed
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