CPT Code 59821 Treatment of Missed Abortion, Completed Surgically; Second Trimester (Abortion Procedures)

CPT 59821 is defined by the American Medical Association (AMA) as “Treatment of missed abortion, completed surgically; second trimester.”

This code applies when the provider surgically removes fetal and placental tissue from the uterus following fetal demise in utero, occurring during the second trimester, typically between 14 and 28 weeks of gestation.

Unlike medical management, this is a therapeutic surgical procedure performed to prevent complications such as hemorrhage, infection, or uterine scarring. The most common methods include dilation and evacuation (D&E) or dilation and curettage (D&C).

Description of the Procedure

When a missed abortion occurs during the second trimester, fetal and placental tissue may remain in the uterus for several weeks. Surgical intervention becomes necessary to remove the contents and restore uterine function.

The provider performs the following steps:

• Dilation of the cervix to allow access to the uterus.
• Evacuation of fetal and placental tissue using suction and surgical instruments (D&E or D&C).
• Inspection of the uterine cavity to ensure complete clearance.
• Hemostasis and uterine tone assessment to control bleeding.

Due to increased fetal size and vascularity, the second-trimester procedure often requires greater surgical skill and time than a first-trimester evacuation (CPT 59820).

When to Use CPT 59821

Use CPT 59821 when:

• A missed abortion occurs in the second trimester (14–28 weeks).
• Fetal cardiac activity is absent, confirmed by ultrasound.
• Surgical evacuation is required to prevent infection, hemorrhage, or sepsis.
• Medical management (e.g., prostaglandins or misoprostol) has failed or is contraindicated.

Do not use CPT 59821 when:

• The abortion occurs in the first trimester (use CPT 59820).
• The procedure is an induced abortion (use CPT 59840).
• The retained tissue is due to postpartum complications (use CPT 59160).

Coding and Billing Guidelines

• Global Period: 90 days
• Site of Service: Typically performed in a hospital or ASC due to higher risk of bleeding.
• Preauthorization: Strongly recommended, many payers require pre-approval for second-trimester procedures.
• Anesthesia: General or regional anesthesia is commonly administered.
• Bundling Rules: Do not separately report suction curettage, cervical dilation, or ultrasound guidance if performed as part of the same procedure.

Applicable Modifiers

• Modifier 22 – Increased Procedural Services: When additional work is required due to fetal size or complications.
• Modifier 52 – Reduced Services: If the evacuation was incomplete or limited by clinical conditions.
• Modifier 59 – Distinct Procedural Service: When an unrelated procedure is performed in the same session.
• Modifier 78 – Return to OR: If the patient requires reoperation within the global period.

Documentation Requirements

For clean claims and audit readiness, ensure documentation includes:

• Confirmation of fetal demise and gestational age (14–28 weeks).
• Surgical method used, D&E or D&C.
• Indication for procedure (e.g., failed medical management, infection risk).
• Details of fetal and placental evacuation.
• Intraoperative findings and complication status.
• Postoperative care plan and patient follow-up instructions.

A complete operative report with ultrasound confirmation and pathology documentation is essential for payer approval.

Example Clinical Scenarios

Scenario 1 – Surgical Evacuation After Fetal Demise at 16 Weeks

A 30-year-old patient presents with no fetal heart activity at 16 weeks. Medical induction is not successful. The provider performs dilation and evacuation (D&E) to remove all products of conception.

Code: CPT 59821

Rationale: Missed abortion in the second trimester, surgically treated via D&E.

Scenario 2 – Retained Fetal Tissue After Incomplete Miscarriage at 18 Weeks

A patient with fetal demise at 18 weeks undergoes partial expulsion of tissue, but ultrasound shows retained placenta. The provider completes the evacuation surgically under ultrasound guidance.

Code: CPT 59821 with Modifier 22

Rationale: Second-trimester missed abortion requiring complex surgical evacuation due to retained placental fragments.

Scenario 3 – Failed Medical Management in 15-Week Pregnancy

A 28-year-old with fetal demise at 15 weeks is treated medically with misoprostol, but the uterus remains filled with tissue. Surgical D&E is performed under anesthesia.

Code: CPT 59821

Rationale: Surgical completion of missed abortion after failed medical management.

Common Coding Challenges

Misclassifying Trimester-Based Codes

Coders sometimes confuse CPT 59820 (first trimester) with 59821 (second trimester). Always verify gestational age from the operative note, documentation of weeks is crucial for payer acceptance.

Lack of Fetal Demise Confirmation

Without documented absence of cardiac activity or ultrasound evidence, payers may reject claims as elective or induced abortions.

Incomplete Documentation of Surgical Method

Whether D&C or D&E was performed, specifying the technique ensures accurate claim processing and medical necessity validation.

Incorrect Use of Induced Abortion Codes

Some coders mistakenly report 59840 instead of 59821. Remember: 59821 applies only to natural fetal demise (missed abortion), not elective terminations.

Missing Preauthorization or Consent

Second-trimester procedures have higher scrutiny. Payers often require written consent, ultrasound proof, and preauthorization before reimbursement.

Overlapping Global Period Billing

All postoperative care within 90 days is included in the global fee, billing separately for follow-up visits can cause denials or audits.

Reimbursement Information

• Average Medicare Reimbursement: Ranges from $550–$750, depending on location and facility type.
• Global Period: 90 days
• Multiple Procedure Reduction: Applies if billed alongside other major surgeries.
• Commercial Payer Variations: Check plan-specific coverage for second-trimester D&E.

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