Incomplete/missed abortion
Incomplete: retained products of conception, missed: demised fetus
Multiple births
One code, additional codes for each delivery
OB package
Includes antepartum, delivery, and postpartum
Diagnostic endoscopies
Included in surgical endoscopy procedures
Urethro vs ureto
Watch for
Stent codes
Assigned when the Stent is left in place
Multiple lesions fulgerated/resected
Code size of largest lesion
Urodynamics
Multiple procedures can be performed, code most significant first
Codes 54150 and 54160
Don’t use modifier 63
Reoperation due to incomplete circumcision
54163
Vasectomy code 55250
Unilateral/bilateral
Post-op semen analysis
Included in vasectomy code
Prostatectomy codes
Assigned based on the extent of incision
TAH
Total abdominal hysterectomy
TAH/BSO
Total abdominal hysterectomy with bilateral salpingo-oophorectomy
TAH/BSO with MMK
Total abdominal hysterectomy with bilateral salpingo-oophorectomy and Marshall-Marzetti-Kranz procedure (colpourethrocystopexy)
Vaginal hysterectomy
Based on grams of uterus
Tubal ligation
Modifier 50 not necessary
VBAC (vaginal birth after cesarean) codes
Assigned regardless of whether delivered vaginally or by c-section
Antepartum services
Initial/subsequent H&P exams, recording of fetus, chemical urinalysis
Delivery services
Admission, management of uncomplicated delivery, delivery
Postpartum services
Visits following delivery
Spontaneous abortion
Included in abortion
D&C (dilation and curettage)
Not coded for abortions