CPT Code 59160 Excision Procedures for Maternity Care and Delivery

CPT 59160 is defined as “Curettage, postpartum” by the American Medical Association (AMA).

This code describes a surgical procedure performed after delivery or abortion to remove retained products of conception (RPOC), such as placental tissue or blood clots that remain in the uterus. It is most often used when excessive bleeding, infection, or incomplete uterine evacuation occurs following childbirth or miscarriage.

Description of the Procedure

The procedure typically involves inserting a curette (a spoon-shaped surgical instrument) into the uterus to remove any remaining tissue gently. The provider may use manual, suction, or sharp curettage depending on the patient’s condition and the clinical findings.

It can be performed:

• After vaginal delivery,
• Following a cesarean section, or
• In cases of incomplete abortion or miscarriage, uterine evacuation is required to stop bleeding and prevent infection.

The goal of CPT 59160 is to restore uterine integrity, control bleeding, and prevent sepsis or further complications.

When to Use CPT 59160

CPT 59160 should be reported when the physician performs postpartum or post-abortion curettage for retained placental or fetal tissue.

It does not apply to diagnostic D&C procedures unrelated to delivery; those are reported with CPT 58120 or 58145.

Typical Indications Include:

• Retained placenta or placental fragments
• Postpartum hemorrhage due to retained tissue
• Infection or suspected endometritis caused by RPOC
• Incomplete spontaneous or induced abortion

Do not report 59160 when:

• Curettage is done as part of a complete delivery package (without retained tissue).
• The procedure is performed for diagnostic purposes only (use 58120).

Coding and Billing Guidelines

• Single Procedure Rule: Report CPT 59160 once per surgical session, even if multiple uterine passes are performed.
• Global Period: This code has a 90-day global period; routine post-op care is included.
• Site of Service: Usually performed in a hospital or ambulatory surgical center; less commonly in an office.
• Bundling Rules: Do not bill with delivery or abortion codes unless the curettage is distinctly documented as a separate, medically necessary procedure.
• Anesthesia: If separately provided, bill with appropriate anesthesia codes.

Applicable Modifiers

Use these modifiers when applicable to clarify billing and provider responsibility:

• Modifier 51: Multiple procedures in one session.
• Modifier 59: Distinct procedural service (if unrelated curettage performed).
• Modifier 78: Unplanned return to the operating room by the same physician.
• Modifier 52: If a reduced service is documented.

Documentation Requirements

Accurate documentation is critical for payer compliance and to justify medical necessity. Ensure operative notes include:

• Reason for curettage (e.g., retained placenta, heavy bleeding)
• Timing (postpartum or post-abortion)
• Description of tissue removed
• Method used (manual, suction, or sharp curettage)
• Estimated blood loss and hemostasis achieved
• Pathology submission confirmation

Example Clinical Scenarios

Scenario 1 – Retained Placental Fragments After Vaginal Delivery

A patient experiences excessive bleeding one hour after delivery. Ultrasound confirms retained placental tissue. The physician performs suction curettage under anesthesia to remove fragments.

Code: CPT 59160 – Postpartum curettage for retained placental tissue.

Scenario 2 – Post-Abortion Retained Tissue

A 28-year-old presents with heavy bleeding and cramping five days after an incomplete abortion. Curettage is performed to remove remaining tissue.

Code: CPT 59160 – Curettage following abortion.

Scenario 3 – Return to OR After Cesarean Delivery

Following cesarean delivery, the patient develops excessive postpartum bleeding due to retained products. The provider performs curettage under anesthesia in the OR.

Code: CPT 59160 with Modifier 78 – Unplanned return to the OR for postpartum curettage.

Common Coding Challenges

Coding postpartum or post-abortion curettage procedures may appear straightforward, but documentation gaps and timing details often lead to errors or claim denials.

Unclear Procedure Timing

The most frequent issue arises when documentation does not specify whether the procedure occurred immediately postpartum or days later. Timing determines whether it’s included in the delivery package or billed separately.

Incomplete Indication Documentation

Coders often face claims denied for “lack of medical necessity” because the reason for curettage (e.g., retained products or bleeding) isn’t clearly stated. Always include the clinical trigger.

Confusion with Diagnostic D&C Codes

If the curettage is performed for postpartum hemorrhage, CPT 59160 applies. For diagnostic D&C or unrelated conditions, use 58120. Verify the operative note’s intent.

Bundling with Delivery or Abortion Services

Payers may deny CPT 59160 when it appears bundled with a delivery or abortion claim. Proper modifier use (e.g., 59 or 78) and separate documentation justify it as a distinct, medically necessary procedure.

Pathology Confirmation Omission

Not sending the removed tissue for pathology review or failing to note it in documentation can cause audit risks. Always confirm pathology submission in the operative report.

Reimbursement Information

• Average Medicare Reimbursement: Approximately $420–$480 (subject to regional variation).
• Global Period: 90 days.
• Multiple Surgery Reduction: May apply if other procedures are performed during the same session.

Always verify with payer-specific fee schedules for updated amounts.

Partner with BillingFreedom for Expert OBGYN Revenue Solutions

Postpartum and post-abortion procedures, such as CPT 59160, require accuracy not only in coding but also in understanding payer rules, modifier usage, and documentation nuances. Even minor discrepancies can result in denials or delayed payments. That’s where BillingFreedom makes a difference.

Our team of certified coders and billing specialists focuses exclusively on OB/GYN medical billing services, ensuring that every claim is submitted cleanly, supported by proper documentation, and fully compliant with the latest CMS and AAPC guidelines.

We don’t just process claims; we optimize your entire revenue cycle by:

• Identifying documentation gaps before claim submission
• Applying precise modifiers to avoid bundling errors
• Monitoring payer trends to reduce denials
• Ensuring every postpartum or surgical procedure meets compliance standards

When you choose BillingFreedom, you’re not just outsourcing billing; you’re gaining a partner who understands the unique challenges of OBGYN practices.

For more details about our exceptional OBGYN billing services, please don't hesitate to contact us via email at info@billingfreedom.com or call us at +1 (855) 415-3472. 

Your financial tranquility is our priority!