How To Use CPT Code 59841

CPT 59841 describes the procedure for induced abortion by dilation and evacuation. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 59841?

CPT 59841 is used to describe the deliberate termination of a pregnancy for elective or therapeutic reasons. The procedure involves dilating the cervix and evacuating the fetus and products of conception using forceps. It is typically performed during the second trimester, between fourteen weeks and less than twenty-eight weeks of gestation.

2. Official Description

The official description of CPT code 59841 is: ‘Induced abortion, by dilation and evacuation.’

3. Procedure

1. The patient is positioned in a dorsal lithotomy position and administered a general or regional anesthetic.
2. A weighted speculum is inserted, and the cervix is cleansed.
3. If the cervix is closed, serial dilation is performed to gradually open the cervix using mechanical dilators.
4. A tenaculum is used to grasp and pull the cervix down.
5. A cannula is inserted from the cervix into the uterine cavity.
6. A suction curettage is performed to drain the amniotic fluid and draw tissue into the lower uterus for extraction using forceps.
7. All fetal parts are removed, and the uterus is scraped with a sharp curette to ensure it is empty.
8. Once the procedure is complete, all instruments are removed, and bleeding is controlled.

4. Qualifying circumstances

CPT 59841 is performed for the deliberate termination of a pregnancy before the age of viability, usually before twenty completed weeks of gestation. It can be done for elective or therapeutic reasons. The procedure is typically performed via a vaginal approach.

5. When to use CPT code 59841

CPT code 59841 should be used when a provider performs an induced abortion by dilation and evacuation. It is important to ensure that the procedure is performed within the appropriate gestational age range and for the intended reasons. This code should not be used for spontaneous abortions or miscarriages.

6. Documentation requirements

To support a claim for CPT 59841, the provider must document the following information:

• Patient’s gestational age and the reason for the induced abortion
• Details of the procedure, including the use of anesthesia and any complications
• Date and duration of the procedure
• Specific instruments used during the procedure
• Confirmation of the completion of the procedure and control of bleeding
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 59841, ensure that the procedure meets the criteria for induced abortion by dilation and evacuation. It is important to follow the appropriate coding guidelines and documentation requirements. CPT code 59841 should not be reported with other abortion procedure codes. It is essential to review the payer’s specific guidelines and policies for accurate billing and reimbursement.

8. Historical information

CPT 59841 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A provider performs an induced abortion by dilation and evacuation for a patient at sixteen weeks of gestation.
2. A woman undergoes an induced abortion by dilation and evacuation for therapeutic reasons at twenty-two weeks of gestation.
3. A patient chooses to have an elective induced abortion by dilation and evacuation at fifteen weeks of gestation.
4. A provider performs an induced abortion by dilation and evacuation for a patient with a medical condition that poses a risk to her health at eighteen weeks of gestation.
5. A woman undergoes an induced abortion by dilation and evacuation due to fetal abnormalities at twenty-six weeks of gestation.
6. A patient opts for an elective induced abortion by dilation and evacuation at seventeen weeks of gestation.
7. A provider performs an induced abortion by dilation and evacuation for a patient at twenty weeks of gestation.
8. A woman undergoes an induced abortion by dilation and evacuation for therapeutic reasons at twenty-three weeks of gestation.
9. A patient chooses to have an elective induced abortion by dilation and evacuation at fourteen weeks of gestation.
10. A provider performs an induced abortion by dilation and evacuation for a patient with a medical condition that poses a risk to her health at nineteen weeks of gestation.