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PROCEDURE: Dilation and Evacuation (D&E)
ANESTHESIA: Moderate sedation

INDICATIONS: The patient is a 29-year-old gravida 1 at 20 weeks and 5/7 days with multiple fetal anomalies, who desires a termination of pregnancy. She has previously had dilators placed.

DESCRIPTION OF PROCEDURE:
- The patient was brought to the operating room, and moderate sedation was administered by the anesthesia team.
- The patient was then placed in the dorsal lithotomy position and was prepped and draped in the usual sterile fashion.
- The dilators were removed, and the patient's cervix was dilated to 5-6 cm.
- A bulging bag ruptured during the vaginal prep.
- A speculum was attempted to be placed, but the fetus was already delivering into the vagina.
- The umbilical cord was severed at this time, and no fetal heartbeat was noted on ultrasound.
- Ultrasound guidance was used for the entire procedure.
- Gentle traction was applied, and the fetus delivered intact. There was no respiratory or cardiac effort noted.
- Bierer forceps were then used to remove the placenta intact.
- A speculum was placed, and an atraumatic tenaculum was placed on the anterior lip of the cervix. A standard D&C was then performed until the characteristically gritty texture was noted on the endometrium.
- A small amount of bleeding was noted from the lower uterine segment; 20 units of Pitocin were added to the patient's IV fluids, and pressure was held against the lower uterine segment for 5 minutes.
- Hemostasis was noted to be excellent.
- The speculum was then removed, and the patient was taken out of the dorsal lithotomy position after her perineum was cleansed.
- The patient's anesthesia was discontinued, and she was brought to the recovery room in stable condition.
- There were no complications during the procedure. The patient tolerated the procedure well.

SPECIMEN(S): The products of conception were sent to pathology for cytogenetics and pathologic evaluation.

PLAN: The patient will follow up in the outpatient clinic.

DIAGNOSIS: Intrauterine pregnancy at 20 weeks and 5/7 days with multiple fetal anomalies.

What are the CPT® and ICD-10-CM codes?

Answer :

Final answer:

The CPT® and ICD-10-CM codes for a dilatation and evacuation procedure for termination of a pregnancy due to multiple fetal anomalies would likely be CPT® code 59855 and ICD-10-CM code O31.1X0 or a code from category Q9X-Q99, reflecting congenital malformations.

Explanation:

The CPT® (Current Procedural Terminology) code for this procedure could be varied depending on the specifics, but it is likely to be 59855 (Induced abortion by dilation and evacuation), as this reflects a second trimester abortion procedure performed via dilation and evacuation (D&E). The ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) code identifying the reason for the procedure might be O31.1X0 (Continuing pregnancy after intrauterine death), or perhaps a code from category Q9X-Q99 (Congenital malformations, deformations, and chromosomal abnormalities) if any specific fetal anomalies can be identified.

This clinical description details the step-by-step process of the D&E procedure that was required due to multiple fetal anomalies. This procedure included administration of anesthesia, dilation of the cervix, delivery of the fetus, removal of the placenta, an application of moderate pressure to control bleeding, and finally the administration of medication to aid in clotting, illustrating the complex nature of medical coding when interpreting clinical procedures and indications.

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