Coding, Classification & Reimbursement

Topic: Missed Abortion with Cytotec Induction

1.  Missed Abortion with Cytotec Induction

Posted 03-02-2017 22:47
Root Operation -- Abortion or Delivery???

Cytotec induction with delivery of dead fetus.

Everyone is all over the place with this one!! Can you help???

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Brenda Ray, CCS, CCS-P, COC
Owner/CEO
TeleCode Healthcare Advisors, LLC
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2.  RE: Missed Abortion with Cytotec Induction

Posted 03-03-2017 07:13
The handbook gives the example, 10A07ZX Abortion by insertion of prostaglandin suppository.  So I'd probably use that. 

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Janie Palmer
Coder
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3.  RE: Missed Abortion with Cytotec Induction

Posted 03-03-2017 08:05

I am going by your thread title of missed abortion with cytotec induction. So, the MD has made a diagnosis of missed abortion. A missed abortion is defined as fetal death that occurs prior to the completion of 20 weeks of gestation. The pregnancy has already been naturally “’terminated.”  The problem is that the dead fetus has not been expelled by the body. Abortion, as per PCS definition is defined as artificially terminating a pregnancy. That is not the case here- again, the pregnancy has already been naturally terminated. The intent of the procedure is to expel the dead fetus, not end an active pregnancy.Therefore, I’d use induction of labor with cytotec, with manual delivery. 



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Jodi Kingley, CCS
Inpatient Coder
Princeton HealthCare System
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4.  RE: Missed Abortion with Cytotec Induction

Posted 03-03-2017 08:22
Also, if you have access to an Optum 2017 PCS coding manual, look at page 803 under Obstetrics. they have coded a a manually assisted spontaneous abortion and assigned code 10E0XZZ with this explanation: Since the pregnancy was not artificially terminated, this is coded to Delivery because it captures the procedure objective. The fact that it was an abortion will be identified in the diagnosis code.

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Jodi Kingley, CCS
Inpatient Coder
Princeton HealthCare System
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5.  RE: Missed Abortion with Cytotec Induction

Posted 03-04-2017 08:53
I agree with Jodi - it's right there in the title/diagnosis - missed abortion, fetal death prior to delivery.

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Laura David, CCS
HIM Coder
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6.  RE: Missed Abortion with Cytotec Induction

Posted 03-06-2017 06:10
The term "missed abortion" does not mean that the mom was in the process of aborting but just missed aborting. The reason this is called "missed" is because the fetus was not expelled from the mom's body, and the mom missed completing the abortion process.  The fetus cannot stay there--it has to be removed.  If the mom's body had expelled the fetal remains, we would be talking about a spontaneous abort.  However, that is not the case here.   Introduction of Cytotec or other med in order to induce expulsion of the fetal remains in a missed abortion is done to complete the abortion process. If this method is not successful, the physicians will then do a D&C to complete the abortion process. This is not a delivery of an infant.   See Coding Clinic, 1Q 2001, Page 5.  The codes have changed with ICD-10, but the Coding Clinic logic remains the same. You cannot code this for induction of labor to deliver an infant.  

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Cynthia Brunette
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7.  RE: Missed Abortion with Cytotec Induction

Posted 03-05-2017 17:16
I agree, this is very confusing and something I have been struggling with as well. I had the exact scenario present itself while coding. As stated, the pregnancy NATURALLY terminated. I agree delivery vs abortion would be more appropriate, in PCS, as the diagnosis code specifies the fetal death. I believe coding 10E0XZZ along with, perhaps, 3E0P7GC is more appropriate. The fact that the patient chose to initiate labor versus waiting for spontaneous expulsion to occur should have no bearing on this scenario - the fetus had already expired - the patient was not initiating an abortion of a live fetus to terminate the pregnancy. Thanks.

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Susan Luehrs, RHIT, CCS
Coding Auditor/Trainer
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8.  RE: Missed Abortion with Cytotec Induction

Posted 04-10-2017 10:42
Would you also code Z37.1 (Single stillbirth) if the fetus is less than 20 weeks? I have a chart where the mom was admitted for fetal demise at 17 weeks and labor was induced with Pitocin. She had retained placenta after delivery of the fetus, so a suction D and C was performed. I've coded 3e033VJ (Pitocin), 10E0XZZ (delivery products of conception, ext) and 10D17ZZ (extraction POC retained). I'm getting a 3M edit that says 10E0XZZ should be reported with an outcome of delivery code.

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Laurie Zawiskie
Coder III
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9.  RE: Missed Abortion with Cytotec Induction

Posted 04-10-2017 11:38
Hi Laurie:

The edit is correct- you code outcome of delivery anytime a delivery is performed, even with missed abortions. You can see the note under Z37 outcome of delivery. This is a great question- this just came up at work for almost the exact same scenario. Your other codes are perfect!

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Jodi Kingley, CCS
Inpatient Coder
Princeton HealthCare System
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10.  RE: Missed Abortion with Cytotec Induction

Posted 04-10-2017 12:04
Thanks, Jodi!

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Laurie Zawiskie
Coder III
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11.  RE: Missed Abortion with Cytotec Induction

Posted 04-11-2017 12:30
Hello!

The sources for the following information are Coding Clinic, 1st Qtr 2001, page 5, and the AHIMA 2016 Trainer's Manual pages 196 and 208 (Exercise 1.118).

According to the Coding Clinic, induced labor for expulsion of a missed abortion should only have the instillation coded and no additional procedure code for the delivery and no diagnosis code for the outcome of delivery.   The D&C for extraction of the retained POC should be coded.

"Assign code 632, Missed abortion, as the principal diagnosis.  Code 658.13, Premature rupture of membranes, antepartum complication or condition, should be assigned as a secondary diagnosis. For the procedure, assign code 96.49, Other genitourinary instillation.  Intravaginal misoprostol (Cytotec) is used as an abortifacient in second trimester missed abortion. Misoprostol induces uterine contractions and stimulates expulsion of the products of conception."   Note no outcome of delivery code is advised.  I can find no subsequent, superseding advice.

At that time the cutoff for the difference between an abortion and fetal demise was 22 weeks.

According to the Trainer's manual, the cutoff differentiating between abortion and fetal death codes has changed from 22 to 20 weeks (page 196).  There is an exercise 1.118 on page 208 involving a spontaneous abortion at 12 weeks.  In the example, no outcome code is assigned but a weeks gestation code is.





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Lawrence Barr
President
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12.  RE: Missed Abortion with Cytotec Induction

Posted 04-11-2017 22:18
Thank you, Lawrence. I understand why Brenda originally posted this question...so many different opinions. Guess I will spend my weekend reading all the resources everyone has provided, so I can get a better understanding of how to code this scenario.

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Laurie Zawiskie
Coder III
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13.  RE: Missed Abortion with Cytotec Induction

Posted 04-11-2017 23:33
Thanks Lawrence!- I reviewed that coding clinic. I could very well be wrong on this.The problem I have is the definition of abortion in PCS is artificially terminating a pregnancy-   the woman is no longer pregnant if she is carrying a dead fetus, correct? Missed abortion: An abortion is a pregnancy that ends before the baby can survive outside the womb because it has not yet reached viability. http://2womenshealth.com/Missed-Abortion.htm


So, since the fetus was already a missed abortion- I am not seeing how we could use an abortion code based on the PCS definition of specifying it as artificial termination. Why didn't they say artificial termination of a viable fetus or therapeutic removal of non-viable products of conception in the definition then?

I do note that you can induce an abortion of a viable fetus with cytotec and I believe that that is what the PCS code is for, given the PCS definition, although this may be a good issue to ask coding clinic to clarify.


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Jodi Kingley, CCS
Inpatient Coder
Princeton HealthCare System
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14.  RE: Missed Abortion with Cytotec Induction

Posted 04-12-2017 09:45
Hello All!

The real problem, in my opinion, is the poorly written Notes in the Classification and  the Guidelines regarding Abortions, Miscarriages, Delivery Before Term (especially at that 20/21 week cutoff), etc.

I double checked this with a colleague.  It appears there is a question of assigning a Z3A Weeks of gestation code for missed, spontaneous, etc. abortions.  We need clearer Guidelines from the Cooperative Parties.

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Lawrence Barr
President
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15.  RE: Missed Abortion with Cytotec Induction

Posted 04-12-2017 10:35
There is no issue here- The note under Z3A states to code first complications of pregnancy, childbirth and the puerperium O00-O9A- this includes the pregnancy with abortive outcome block. So you would code weeks gestation if known.Sometimes this information is not provided/not known or is not specific (which we couldn't use during an outpatient encounter to remove the fetus).

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Jodi Kingley, CCS
Inpatient Coder
Princeton HealthCare System
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16.  RE: Missed Abortion with Cytotec Induction

Posted 04-13-2017 08:06
Edited by Lawrence Barr 04-13-2017 08:09
Hello!

According to Coding Clinic, 3rd Qtr. 2014 pages 17 - 18:  "Codes in category Z3A, Weeks of gestation are not applicable, and should not be assigned if the pregnancy is outside of the uterus or otherwise nonviable (categories O00-O02)."  The Coding Clinic goes on to state that the NCHS would consider a "proposal to revise the conflicting note in the Tabular List."

As previously stated, the problem is with poorly written notes, instructions, etc. published in the Classifications, Guidelines, and other official sources.



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Lawrence Barr
President
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17.  RE: Missed Abortion with Cytotec Induction

Posted 04-13-2017 09:47
Lawrence:
As I said in my prior comment, the tabular has already made that clear. They corrected the issue to which you referred.
Remember order of using coding references:
classification system (alpha and tabular)>coding guidelines>coding clinics

Thanks,
Jodi

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Jodi Kingley, CCS
Inpatient Coder
Princeton HealthCare System
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18.  RE: Missed Abortion with Cytotec Induction

Posted 25 days ago
Edited by Kayla Hill 25 days ago
I think the original question was whether to use a delivery PCS code or an abortion PCS code if there is a fetal demise at less than 22 weeks and the mother is induced with Cytotec.  I don't know if that was ever answered.  The question I have is, if there is a fetal demise at greater than 22 weeks (30 weeks) and the mother is induced with Cytotec for cervical ripening, Pitocin, and has a transcervical Foley balloon inserted, do you use a delivery PCS code or an abortion PCS code?  The weeks gestation question should work itself out depending on the CM code you use, right? The guidelines are very confusing or actually nonexistent on some of this.
Thanks for any help!!

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Kayla Hill, RHIA
Director of Health Information/Privacy/CDI
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