CPT® Code 59855

1. Indications

The procedure coded as CPT® 59855 is indicated for the termination of pregnancy through induced abortion. The specific indications for this procedure include:

• Therapeutic Abortion - The procedure is performed to terminate a pregnancy for medical reasons, which may include maternal health concerns or fetal anomalies.
• Second Trimester Abortion - This procedure is particularly indicated for pregnancies in the second trimester, where cervical dilation may be necessary to facilitate the abortion process.

2. Procedure

The procedure for an induced abortion using CPT® 59855 involves several detailed steps:

• Hospital Admission - The patient is admitted to the hospital for the procedure, where she will be monitored throughout the process.
• Cervical Preparation - If the abortion is performed in the second trimester, passive dilators such as laminaria or a balloon catheter may be inserted into the cervix to facilitate dilation.
• Administration of Vaginal Suppositories - One or more vaginal suppositories, which may include prostaglandin agents, are inserted into the vaginal fornix to induce uterine contractions and facilitate the abortion.
• Monitoring - Continuous monitoring of uterine and fetal activity is conducted, along with the vital signs of the mother, to ensure safety and effectiveness.
• Additional Doses - Additional vaginal suppositories may be administered at intervals of 6 to 12 hours as needed to enhance the effectiveness of the procedure.
• Delivery of Fetus and Secundines - The fetus and placenta are delivered vaginally, and the products of conception are inspected to verify that the abortion is complete.
• Management of Incomplete Abortion - If an incomplete abortion occurs, a dilation and curettage (D&C) or evacuation is performed. This involves placing a speculum in the vagina, exposing and cleansing the cervix with antiseptic solution, and using a tenaculum to grasp the anterior cervical lip.
• Uterine Evaluation - A sound is passed to determine the depth and angle of the uterus, followed by the insertion of a curette through the cervix to scrape or suction the uterine wall. The tissue obtained is sent for pathology examination.
• Post-Procedure Care - After the procedure, the tenaculum is removed, and any bleeding from the cervix is controlled with pressure to ensure patient safety.

3. Post-Procedure

Following the completion of the procedure, the patient is monitored for any complications or signs of incomplete abortion. If the abortion is confirmed to be complete, the patient may be provided with post-procedure care instructions, which may include follow-up visits to ensure recovery and address any concerns. In cases where a dilation and curettage or evacuation was performed due to an incomplete abortion, additional monitoring and care may be necessary to manage any potential complications. The administration of intravenous oxytocin may also be indicated to help contract the uterus and reduce the risk of excessive bleeding.