Sunday, January 3, 2016

Interrupted Pregnancy:  Tubal, Ectopic, and other Abnormal Pregnancies

04.26.2015 -  Lori-Lynne Webb 

The definition of an abnormal pregnancy is when a fertilized egg does not attach within the normal area of the uterus, and attaches in other abnormal areas within the internal female genital organs, or pelvic cavity.   There have been cases where the egg can attach within the abdominal cavity, stomach area or even the cervix.  Ectopic pregnancies occur in one out of every 50 pregnancies within the United States, however some statistics state it happens more frequently.  Worldwide statistics note that abnormal pregnancy to be more representative of 1 in every 100 pregnancies.

A pregnancy that has attached in an inappropriate environment outside the uterus has an extremely low change of survival, and can cause extreme complications within the mother.  In the best interest of the mother, immediate treatment of an abnormal pregnancy requires definitive and speedy diagnosis, then a decision and undertaking of the surgical or medical management. 

The most common names that you will encounter for an abnormal pregnancy are:
·         Abdominal Pregnancy
·         Tubal Pregnancy
·         Ectopic Pregnancy

Within an “ectopic” pregnancy the egg can attached under these sites within the pelvic organ itself. (see illustration)
·         Cervical
·         Ovarian
·         Ampullary
·         Cornual
o   Interstitial
·         Isthmic
·         Fimbrial

The causes of an abnormal pregnancy are not fully understood or known, but are attributed to being caused by a blockage or slowed movement of a fertilized egg through the fallopian tube to the uterus.  

If the diagnosis of an abnormal pregnancy is confirmed extremely early,  medical management of the condition can be undertaken.  The drug, methotrexate may be given, in which this allows the body to absorb the pregnancy tissue.  If caught soon enough this may be enough to save the fallopian tube or ovary, but is dependent upon how far the abnormal pregnancy tissue has developed.

If the pregnancy has progressed further than medical management can correct, then surgical intervention will be needed.  Oftentimes, the surgical intervention requires removal of part or all of the fallopian tube and/or ovary.  If the tube has been ruptured and is bleeding, emergent surgery may be required, rather than a planned admission for surgical management . 

Surgical management of an abnormal pregnancy can be performed as an “open” or incisional operative case, or as a laparoscopic surgery.   Either surgical approach/procedure involves removing the area of the abnormal pregnancy and may require removal of a fallopian tube or ovary. 

Coding for Abnormal Pregnancy Diagnosis and Surgical Procedures

CPT has provided us surgical procedure codes for the treatment of these type of pregnancies with the codes

Ø  59120 Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring salpingectomy and/or oophorectomy, abdominal or vaginal approach

Ø  59121 Surgical treatment of ectopic pregnancy; tubal or ovarian without salpingectomy and/or oophorectomy

Ø  59130 Surgical treatment of ectopic pregnancy; abdominal pregnancy

Ø  59135 Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy requiring total hysterectomy

Ø  59136 Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy with partial resection of uterus

Ø  59140 Surgical treatment of ectopic pregnancy; cervical, with evacuation

Ø  59150 Laparoscopic treatment of ectopic pregnancy, without salpingectomy and/or oophorectomy

Ø  59151 Laparoscopic treatment of ectopic pregnancy, with salpingectomy and/or oophorectomy

As you can see from the listing above each one of these codes is very specific as to what the procedure approach is, and what areas are being addressed in the management of the diagnosis.   If you note with codes 59135 and 59136 it is addressed for an interstitial pregnancy, which is defined as a pregnancy location outside the normal area of the uterus but within the uterine cavity in one of the upper “horns” of the uterus and has attached within that small muscular area where the uterine wall and the fallopian tube meet.   An interstitial pregnancy should not be confused with a pregnancy that is diagnosed as an isthmic tubal pregnancy.  An isthmic tubal pregnancy is further down within the tube at the area of the isthmus.

Coders need to be diligent in understanding where the pregnancy is located prior to coding for the operative procedure.  If the physician has not provided clear documentation where the abnormal pregnancy is located, the coder should query the physician and ask for the operative report be amended to clearly confirm the diagnosis and anatomic location.   Another caveat for coding procedures for abnormal/ectopic pregnancy is to carefully review if both the tubes and ovary are removed, and if there are any further diagnoses that need coded  in regard to the specific procedure. 

The diagnoses for ectopic procedures in ICD-9 are very straightforward and are contained in the code set of codes 633 Ectopic Pregnancy.  All of the codes within the ectopic pregnancy codes clearly state abdominal, tubal, ovarian, other and unspecified ectopic pregnancy.  However, if the physician has not specified what type of ectopic it is, the coder should query and have the physician correct the record by amending the  medical operative record and diagnosis. 

633 Ectopic pregnancy
·         633.00 Abdominal pregnancy without intrauterine pregnancy
·         633.01 Abdominal pregnancy with intrauterine pregnancy
·         633.10 Tubal pregnancy without intrauterine pregnancy
·         633.11 Tubal pregnancy with intrauterine pregnancy
·         633.20 Ovarian pregnancy without intrauterine pregnancy
·         633.21 Ovarian pregnancy with intrauterine pregnancy
·         633.80 Other ectopic pregnancy without intrauterine pregnancy
·         633.81 Other ectopic pregnancy with intrauterine pregnancy
·         633.90 Unspecified ectopic pregnancy without intrauterine pregnancy
·         633.91 Unspecified ectopic pregnancy with intrauterine pregnancy

As we transition to ICD-10 the clinical documentation becomes much more important for coders to accurately code and bill for ectopic pregnancies and include all pertinent diagnoses.

The ICD-10 crosswalk for ectopic pregnancies is not much larger than that held in ICD-9, but again requires the coder to know the type of ectopic pregnancy.  This listing below shows the ICD-10cm codes that are assigned to Abdominal, Tubal, Ovarian, Other ectopic, and Unspecified Ectopic pregnancy. As you can see this listing is set up nearly identical to the ICD-9 section, but is more comprehensive in regard to the codes themselves.  The other caveat to coding in ICD-10 is that the alpha character “O” denotes the code set followed by a “zero” numeric character.  This can be confusing when performing diagnosis coding with the ICD-10 code set.  

Ectopic pregnancy
·         O00.0 Abdominal pregnancy
o   Excludes1: maternal care for viable fetus in abdominal pregnancy (O36.7-)
·         O00.1 Tubal pregnancy
o   Fallopian pregnancy
o   Rupture of (fallopian) tube due to pregnancy
o   Tubal abortion
·         O00.2 Ovarian pregnancy
·         O00.8 Other ectopic pregnancy
o   Cervical pregnancy
o   Cornual pregnancy
o   Intralegamentous pregnancy
o   Mural pregnancy
·         O00.9 Ectopic pregnancy, unspecified

At this point in time, where we are transitioning from ICD-9 to ICD-10cm it is wise to dual code in both ICD-9 and ICD-10cm to become familiar with the new code set and how the codes cross walk between the two code sets.  The GEMS crosswalk cannot be counted on to be accurate.  The only way to fully ensure you are coding correctly in ICD-10cm is to do the full look-up process for each code that you have chosen in ICD-9. 

Operative Cases -  applying your knowledge

Case #1:
A 31-year-old white female admitted to the hospital.  Patient presented with pelvic pain and vaginal bleeding. After workup the diagnosis of right ruptured ectopic pregnancy with possible hemoperitoneum was established.  Ultrasound performed in the Emergency Department confirmed ruptured tubal pregnancy.  There was no gestation products noted in the uterus.   The patient was taken emergently to surgery and a laparotomy was performed to include a right-side salpingectomy with no complications -   confirmed findings of a right ruptured ectopic pregnancy.

CPT procedure:
59120 Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring salpingectomy and/or oophorectomy, abdominal or vaginal approach        

Final Diagnosis:

ICD-9:  633.10 Tubal pregnancy without intrauterine pregnancy
ICD-10cm: O00.1 Tubal pregnancy  

Case #2

The patient is a 22-year-old who presented to our office this a.m. with extreme left sided pain and a positive pregnancy test.  A quick-peek ultrasound in our office confirmed a mass near the left tube with a possible ruptured left ectopic pregnancy.  Ultrasound did not show any gestational contents within the uterus.   Patient was admitted to day surgery for emergent diagnostic laparoscopy.

Operative Findings: Tortuous left fallopian tube with evidence of ruptured ectopic pregnancy and extensive adhesions. 
Procedure: After obtaining informed consent, the patient was taken to the operating room where general endotracheal anesthesia was administered. She was examined under anesthesia. An 8-10 cm anteverted uterus was noted. The patient was placed in the dorsal-lithotomy position and prepped and draped in the usual sterile fashion for a laparoscopic diagnostic procedure. Attention was then turned to the patient's abdomen where a 5-mm incision was made in the inferior umbilicus. The abdominal wall was tented and VersaStep needle was inserted into the peritoneal cavity. Access into the intraperitoneal space was confirmed by a decrease in water level when the needle was filled with water. No peritoneum was obtained without difficulty using 4 liters of CO2 gas. The 5-mm trocar and sleeve were then advanced in to the intra-abdominal cavity and access was confirmed with the laparoscope.

The above-noted findings were visualized. A 5-mm skin incision was made approximately one-third of the way from the ASI to the umbilicus at McBurney's point. Under direct visualization, the trocar and sleeve were advanced without difficulty. A third incision was made in the left lower quadrant with advancement of the trocar into the abdomen in a similar fashion using the VersaStep. Care was undertaken, as not to disturb the uterus or bladder.  The peritoneal fluid was aspirated and sent for culture and wash and cytology. The abdomen and pelvis were surveyed with the above-noted findings. Evidence of tortuous adhesions of the ovary and fallopian tube were noted and gently lysed.  Ruptured Left tubal ectopic pregnancy was noted in the left fallopian tube near the fimbrii.  Salpingectomy removal of the entire right tube was undertaken.  Entire left fallopian tube with fimbrii and products of conception forwarded to pathology.  Hemoperitoneum was noted and suctioned.  All sites cauterized as needed. The instruments were removed from the abdomen under good visualization with good hemostasis noted. The patient tolerated the procedure well and was taken to the recovery room in stable condition.

CPT procedure:
59151 Laparoscopic treatment of ectopic pregnancy, with salpingectomy and/or oophorectomy
Final Diagnosis:
ICD-9:  633.10 Tubal pregnancy without intrauterine pregnancy
ICD-10cm: O00.1 Tubal pregnancy  

Case #3
Patient is a 40 year old Gravida 3 followed by me for a possible left ovarian pregnancy for the last 2 weeks status post methotrexate.  Today she presented with acute LLQ pain.  Repeat u/sound finding of a solid mass adjacent to the ovary, and no free fluid in the pelvis.   I decided to undertake a laparosopic evaluation.  Patient was consented and admitted to emergent day surgery.

Findings:  Hemorrhagic right ovary with rupture,  Right ectopic tubal pregnancy

Procedure:  Patient was placed in low lithotomy position, and sterile prepped and draped.  A small infraumbilical incision made, and a veress needle was inserted.  Attempts at insufflation were unsuccessful, and after 3 attempts at placement, it was decided to proceed with open hasson trocar.   Peritoneal cavity was entered bluntly and the Hasson was placed.  Peritoneum was insufflated and a 10mm trocar placed under direct visualization to the left of the umbilicus and a 5mm to the right.  A suprapubic trocar was then placed.  Pelvis was inspected and right tube and ovary appeared normal.

On the left, the adnexa was very stuck lateral to the sigmoid, rectum and deep into the cul-de sac.  After some manipulation it was noted that both the ovary and tube were very enlarged and purple.  There was a definite separation between the tube and the ovary however both were involved. The ovary was densely adherent to the left pelvic sidewall and had essentially and a hemorrhagic polycystic ovary appearance.  It was determined due to the extensive nature of the hemorrhage, we would remove the ovary in addition to the tube.  The left tube had a ruptured ectopic pregnancy within the mid-section of the tube with pronounced tubal dilation but no definite rupture of the tube at this time.   The lateral peritoneum to the sigmoid was incised with a scissors to try to mobilize the sigmoid medially to get to the tube and ovary.  With some blunt dissection the left tube was freed and also the left ovary.  A 10mm ligasure was brought across the tube near the uterus and cut, then brought along the mesosalpinx and the tube was excised.  The same procedure was performed to excise the ovary.  Both specimens were removed through the umbilical port site.  The Adnexa was irrigated and hemostasis appeared good.    Blood loss was around 50cc. Patient taken to recovery in satisfactory condition.

CPT Procedure:
59151 Laparoscopic treatment of ectopic pregnancy, with salpingectomy and/or oophorectomy

ICD-9:  633.10 Tubal pregnancy without intrauterine pregnancy
256.4   Polycystic ovaries

ICD-10cm:       O00.1 Tubal pregnancy  
E28.2 Polycystic ovarian syndrome

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at or you can also find current coding information on her blog site:   

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