tci ED Coding & Reimbursement Alert - 2005 Issue 9

REDAER QUESTIONS: Use E/M for Spontaneous Abortion

Question: The patient presented to the ED with abdominal pain and vaginal bleeding. The patient then spontaneously delivered the fetus and placenta. The patient's diagnosis was -complete abortion at 18 weeks- gestational age.- Should I use code 59409 for an 18-week delivery, or is this code intended only for full-term deliveries?Iowa Subscriber Answer: No, you shouldn't report 59409 (Vaginal delivery only [with or without episiotomy and/or forceps]) for the delivery, because the ED physician's services are included in the evaluation and management code.According to the Fall 1993 CPT Assistant, -When a spontaneous abortion that is complete...

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