How To Use CPT Code 59856

CPT 59856 describes the procedure for induced abortion using vaginal suppositories, with or without cervical dilation, including hospital admission and visits, delivery of fetus and secundines, and dilation and curettage. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 59856?

CPT 59856 can be used to describe the procedure for induced abortion using vaginal suppositories, with or without cervical dilation. This code includes hospital admission and visits, delivery of the fetus and secundines, and dilation and curettage. It is typically performed after the first trimester of pregnancy, or after fourteen weeks and zero days gestation.

2. Official Description

The official description of CPT code 59856 is: ‘Induced abortion, by 1 or more vaginal suppositories (eg, prostaglandin) with or without cervical dilation (eg, laminaria), including hospital admission and visits, delivery of fetus and secundines; with dilation and curettage and/or evacuation.’

3. Procedure

1. The provider admits the patient to the hospital and performs an admission history and physical.
2. The patient is placed in a dorsal lithotomy position.
3. A laminaria is inserted into the cervix to dilate it.
4. Vaginal suppositories, such as prostaglandin, are inserted every three to four hours to induce labor contractions.
5. The provider monitors the patient’s labor progress until it fails.
6. The patient is prepared for a dilation and curettage procedure to remove the products of conception.
7. The patient is placed back into a dorsal lithotomy position and given a general or regional anesthetic.
8. A speculum is inserted, the cervix is cleansed, and serial dilation is performed if necessary.
9. The provider uses a manual or electric suction aspirator to remove all products of conception from the uterine cavity.
10. The instruments are withdrawn, bleeding is controlled, and the patient is provided with post-procedure care until discharge.

4. Qualifying circumstances

CPT 59856 is performed when a patient fails to abort the fetus or the placenta after the insertion of vaginal suppositories and possible cervical dilation. The procedure involves the admission of the patient to the hospital, the insertion of suppositories and cervical dilator, management of labor, and the subsequent dilation and curettage. It is typically performed after the first trimester of pregnancy.

5. When to use CPT code 59856

CPT code 59856 should be used when the provider performs an induced abortion using vaginal suppositories, with or without cervical dilation, and includes hospital admission and visits, delivery of the fetus and secundines, and dilation and curettage. It is important to note that this code is typically used for abortions performed after the first trimester of pregnancy.

6. Documentation requirements

To support a claim for CPT 59856, the provider must document the following information:

• Patient’s gestational age and indication for the induced abortion
• Details of the vaginal suppositories used and any cervical dilation performed
• Date of hospital admission and start and end times of the procedure
• Procedure notes, including the steps performed during the dilation and curettage
• Post-procedure care provided to the patient
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 59856, ensure that the procedure meets the criteria outlined in the official description. It is important to report this code only for induced abortions using vaginal suppositories, with or without cervical dilation, and including hospital admission and visits, delivery of the fetus and secundines, and dilation and curettage. It is also important to follow any specific billing guidelines provided by the payer or coding guidelines.

8. Historical information

CPT 59856 was added to the Current Procedural Terminology system on January 1, 1995. The code underwent a change on January 1, 2010, with an updated description. It was also added to the Inpatient Only (IPO) list for Medicare in 2017.

9. Examples

1. A patient at 16 weeks gestation undergoes an induced abortion using vaginal suppositories and cervical dilation. The provider admits the patient to the hospital, inserts the suppositories and dilator, manages the labor, and performs a dilation and curettage to remove the products of conception.
2. A patient at 18 weeks gestation undergoes an induced abortion using vaginal suppositories without cervical dilation. The provider admits the patient to the hospital, inserts the suppositories, manages the labor, and performs a dilation and curettage to remove the products of conception.