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An incomplete abortion, also known as a spontaneous incomplete abortion, is a condition that can occur during any trimester of pregnancy. This situation arises when some of the products of conception, such as fetal tissue or the placenta, have been expelled from the uterus, but not all of the tissue has been removed. The retained tissue can lead to complications, including infection or excessive bleeding, necessitating surgical intervention to complete the abortion process. The surgical treatment involves a series of carefully executed steps to ensure the safe removal of the remaining products of conception. The procedure typically begins with the placement of a speculum to visualize the cervix, followed by cleansing the area with an antiseptic solution to minimize the risk of infection. A tenaculum is then used to grasp the anterior cervical lip, allowing for further examination and treatment. The depth and angle of the uterus are assessed using a sound, and the cervix is prepared for dilation, which may involve the use of metal rods or a laminaria tent. The final step involves the insertion of a curette to scrape or suction the retained tissue from the uterine wall, with the removed tissue sent for pathology examination to ensure proper evaluation. This comprehensive approach is essential for the effective management of an incomplete abortion, ensuring the patient's safety and health are prioritized throughout the procedure.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 59812 is indicated for the treatment of an incomplete abortion, which can occur during any trimester of pregnancy. The following conditions may warrant this surgical intervention:
The surgical treatment of an incomplete abortion involves several critical steps to ensure the safe and effective removal of retained products of conception. The procedure begins with the placement of a speculum into the vagina, which allows for visualization of the cervix. Once the cervix is exposed, it is cleansed with an antiseptic solution to reduce the risk of infection. Following this, a tenaculum is used to grasp the anterior cervical lip, providing stability and access to the cervical canal. A sound is then passed into the uterus to determine its depth and angle, which is essential for the subsequent steps of the procedure.
To facilitate access to the uterine cavity, the cervix must be numbed and dilated. This is achieved by passing a series of metal rods of increasing diameter into the cervical canal, which gradually opens the cervix. Alternatively, a laminaria tent may be inserted into the cervix 8 to 20 hours prior to the procedure. The laminaria absorbs moisture and swells, effectively dilating the cervical canal over time. Once adequate dilation is achieved, a curette is inserted through the cervix into the uterine cavity. The curette is then used to scrape or suction the retained products of conception from the uterine wall. This step is crucial for ensuring that all remaining tissue is removed to prevent complications. After the procedure, the tissue that has been removed is sent for pathology examination to assess for any abnormalities. Finally, the tenaculum is removed, and any bleeding from the cervix is controlled through the application of pressure.
After the completion of the surgical procedure for an incomplete abortion, patients are typically monitored for any immediate complications, such as excessive bleeding or signs of infection. Post-procedure care may include instructions for managing discomfort, such as the use of over-the-counter pain relief medications. Patients are advised to avoid strenuous activities and sexual intercourse for a specified period to allow for proper healing. Follow-up appointments may be scheduled to ensure that the uterus has returned to its normal state and to discuss the pathology results of the removed tissue. It is essential for patients to be aware of the signs of potential complications, such as persistent heavy bleeding, fever, or severe abdominal pain, and to seek medical attention if these occur.
| Short Descr | TREATMENT OF MISCARRIAGE | Medium Descr | TX INCOMPLETE ABORTION ANY TRIMESTER SURGICAL | Long Descr | Treatment of incomplete abortion, any trimester, completed surgically | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 127 - Dilatation and curettage (D&C), aspiration after delivery or abortion |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AG | Primary physician | GC | This service has been performed in part by a resident under the direction of a teaching physician | GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit |
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| 1990-01-01 | Added | First appearance in code book in 1990. |