CPT 59841: Second-Trimester Dilation and Evacuation with Forceps
CPT code 59841 represents a second-trimester dilation and evacuation (D&E) performed via a vaginal approach in which the cervix is dilated and the fetus and products of conception are removed using forceps. The code covers elective and therapeutic pregnancy terminations performed between 14 weeks, 0 days and less than 28 weeks, 0 days. Nationally, this code is clinically significant because it defines billing for a time-sensitive gynecologic surgical service that requires surgical facilities, trained providers, and perioperative care.
Key payers addressed in this publication include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context and typical sites of service for CPT code 59841, a summary of common billing modifiers associated with operative gynecologic services (provided in the input), and guidance on the types of benchmarks and policy updates commonly relevant to second-trimester surgical abortion services. The content outlines expected service delivery settings (hospital operating room or ambulatory surgical center) and highlights that care involves operative gynecology and anesthesia resources.
This publication is intended for billing and compliance teams, clinical administrators, and policy analysts seeking a clear, national-level reference on CPT code 59841, including what the code represents, where the service is typically performed, and which major payers are commonly involved. Data not available in the input is noted where applicable.
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Billing Code Overview
CPT code 59841 describes a deliberate termination of pregnancy performed via a vaginal approach during the second trimester (from 14 weeks, 0 days to less than 28 weeks, 0 days). The provider dilates the cervix and evacuates the fetus and products of conception using forceps. This procedure is an operative gynecologic service performed for elective or therapeutic reasons.
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Service type: Second-trimester surgical abortion by dilation and evacuation with forceps
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Typical site of service: Hospital operating room or ambulatory surgical center with appropriate surgical and anesthesia support
Clinical & Coding Specifications
Clinical Context
A 22–24-week pregnant patient presents to an ambulatory surgical center or hospital gynecology unit seeking termination of pregnancy for therapeutic or elective reasons. After informed consent and preoperative evaluation (history, physical, Rh status, ultrasound confirmation of gestational age and fetal presentation, baseline labs including CBC and blood type), the patient undergoes cervical preparation (osmotic dilators or pharmacologic agents) followed by dilation and evacuation under regional or general anesthesia. The provider dilates the cervix and evacuates fetal and placental tissue using forceps and suction curettage via a transvaginal approach. Postoperative monitoring includes vital signs, uterine tone assessment, bleeding evaluation, analgesia, Rh immunoglobulin administration if indicated, and discharge instructions with follow-up arranged in clinic within 1–2 weeks. Typical site of service is an operating room or ambulatory surgical center with capabilities for second‑trimester procedures and emergency support; inpatient hospital admission is used if complications occur or for concurrent medical issues.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | Standard professional and technical components combined | Rarely used; not typically applied to surgical procedures that are not split component services |
22 | Increased procedural service | Use when work required is substantially greater than typical for 59841 (document reasons) |
23 | Unusual anesthesia | Use when general anesthesia is used for a normally local/regional procedure due to unusual circumstances |
25 | Data not available in the input. | Data not available in the input. |
26 | Professional component | Not generally applicable; included here for completeness when separate professional component exists |
50 | Bilateral procedure | Not applicable to 59841 but retained for coding contexts involving bilateral surgical services |
51 | Multiple procedures | Use when 59841 is billed with additional unrelated procedures on the same day (list additional procedure) |
52 | Reduced services | Use when the service performed was partially reduced or not completed (document reason) |
53 | Discontinued procedure | Use when 59841 is started but discontinued due to extenuating circumstances |
59 | Distinct procedural service | Use to indicate a distinct procedure or service not normally reported together when applicable |
76 | Repeat procedure by same physician | Use if 59841 is repeated by the same physician during the postoperative global period |
78 | Return to OR for a related procedure during global period | Use if the patient returns to the operating room for a complication related to 59841 |
79 | Data not available in the input. | Data not available in the input. |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
207Q00000X | Obstetrics & Gynecology | Most common specialty performing second‑trimester D&E procedures |
207R00000X | Family Medicine | Family physicians with procedural training may perform pregnancy termination in some settings |
2080P0002X | General Practice | General practitioners in certain regions may provide reproductive health procedures |
363L00000X | Nurse Practitioner | Advanced practice clinicians who perform or assist in reproductive surgical procedures |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
O04.12 | Complications following termination of pregnancy, second trimester | Directly relevant for coding post‑procedural complications after 59841 |
O04.13 | Failed attempted termination of pregnancy, second trimester | Relevant when initial termination attempt is unsuccessful and additional procedures are required |
O02.1 | Missed abortion | May be an indication for dilation and evacuation in the second trimester |
O03.9 | Spontaneous abortion, incomplete or unspecified | Dilation and evacuation may be performed for retained products in the second trimester |
Z33.2 | Encounter for elective termination of pregnancy | Used to indicate elective termination as the reason for the procedure |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
59840 | Induced termination of pregnancy, dilation and evacuation, completed in the first trimester (less than 14 weeks) | Performed for earlier gestational ages; contrasted with 59841 which is second‑trimester |
59850 | Induced termination of pregnancy, intrauterine injection; by transcervical instillation (e.g., injection of intracardiac potassium chloride) | May be used in selective fetal reduction or preparation steps in complex second‑trimester cases |
01995 | Supplement anesthesia services for procedures by the same anesthesiologist on the same day (example code) | Anesthesia services are commonly reported separately when general or regional anesthesia is provided for 59841 |
59400 | Routine obstetric care including antepartum care, vaginal delivery, and postpartum care | Not directly related but relevant when termination decisions occur in an obstetric practice setting |
99024 | Postoperative follow‑up visit during a global period unrelated to the usual postoperative care | Used for documentation of services related to complications or additional evaluation after 59841 |