CPT Knowledgebase - Jun 18, 2015

Would an appropriate level emergency department (ED) evaluation and management (E/M) code or code 59409 be reportable in the following scenario: Patient presented to the ED with vaginal bleeding, pelvic cramping, reportedly with passing clots and possibly tissue fragments. Pelvic examination by the ED physician revealed blood, clots, and tissue in the vaginal vault. Using forceps and gentle traction, what appeared to be a complete embryo and placenta sac (less than 12-weeks gestation) was delivered.

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