The code for less than 8 weeks gestation and more than 42 weeks gestation does not follow this pattern. Both O80 and O82 state to use an additional code to indicate outcome of delivery Z37. Example: Patient presents for 32 week monochorionic —diamniotic twin pregnancy. Scenario 2 This scenario offers an additional example of how to code encounters following this guideline. No complaints, no fluid leaking, labor precautions given, and fetal kick counts explained. He has also developed diabetic cataract in his right eye. Scenario 1 Premature delivery at 32 weeks; premature rupture of membranes, onset of labor five hours later; twin gestation; cord around neck without compression for both fetus one and fetus two; both fetuses are liveborn.
Twin Pregnancy coding is challenging and can be tricky. Maternity Only Code is only used for diagnoses related to pregnancy. For example, gestational diabetes does not include designations for trimesters as it usually occurs in the second or third trimester. Answers to coding exercises: 1 I47. There are situations where a mother might continue to use alcohol during the periods leading to child birth, during this period a baby may be affected by alcohol.
New coding concepts for Obstetrics include more specific codes to identify the trimester for complications of pregnancy, the weeks of gestation, and provides a 7 th character option to identify a fetus when the care of the mother is altered during the pregnancy. The note states a delivery, requiring minimal or no assistance, with or without episiotomy, without fetal manipulation rotation version or instrumentation forceps of a spontaneous, cephalic, vaginal, full term, single, liveborn infant. For example, a patient at 27 weeks and five days gestation is admitted to the hospital with complications from a bladder infection and pre-existing essential hypertension. In this situation, the trimester character for the antepartum complication code should be assigned based on the trimester when the complication developed, not the trimester of discharge. Preeclampsia increases the risk of poor outcomes for both the mother and the baby.
Instructional note at the beginning of Chapter 15 states to use an additional code from Category Z3A to report weeks of gestation. If 1 or more of the conditions you listed were discovered at the time of a previous scan and now require ongoing monitoring, use code 76816. Use of this Web site is subject to the and. The 7 th character extension is required for code categories O31, O32, O33. The alphabetic look-up for the weeks of gestation is Pregnancy, weeks of. Scenario 2 Premature delivery at 33 weeks; face presentation; cord around neck without compression; single liveborn. A normal vaginal delivery of a single gestation is reported with O80.
National Center for Health Statistics. The patient is 28 weeks and two days gestation at the time of discharge. This code is for use as a single diagnosis code and is not to be used with any other code from Chapter 15. A secondary code from category F10, Alcohol related disorders, is also assigned to identify manifestations of the alcohol use. An answer key is provided below so you can verify if your answers are correct. Pregnancy, delivered at 39 weeks of gestation; single liveborn; tobacco dependence; patient smokes two packs of cigarettes daily.
Scenario 1 This scenario offers an example of how to code encounters following this guideline. Selection of Trimester for Inpatient Admissions that Encompass More than One Trimester This new guideline for selection of trimester for inpatient admissions that encompass more than one trimester is applicable for those situations in which a patient is admitted to the hospital for pregnancy complication s during one trimester and remains in the hospital into a subsequent trimester. A Your choice of code will depend on what was documented previously and which elements of the scan are being documented at the present time. A 'billable code' is detailed enough to be used to specify a medical diagnosis. If left untreated, it may result in seizures at which point it is known as eclampsia. A secondary code from category F17, Nicotine dependence, should also be assigned to identify the type of nicotine dependence. Gestational age is 36 weeks 1 day.
Q When a patient is scanned during the third trimester for indications such as advanced maternal age, pregnancy-induced hypertension, a large-for-gestational-age fetus, oligohydramnios, or shortened cervix, which code should I use: 76811, 76815, or 76816? This indicates that this is the only other code that can be reported with O80 and O82. When it is not possible to determine the fetus affected or the pregnancy is for a single gestation, the seventh character of 0 zero is used for the 7 th character. Any pregnancy induced by hypertension without a significant proteinuria in the second trimester will be specified by the code 013. Fetus 1 is observed on ultrasound to be small for gestational age. It all boils down to what was known before this scan was ordered. If 1 or more of the conditions mentioned are only now in evidence, use code 76815.
. If you are scanning for 1 or more of the conditions you have listed but not performing all the elements included in 76811, your coding choice is either 76815 ultrasound, pregnant uterus, real time with image documentation, limited or 76816 ultrasound, pregnant uterus, real time with image documentation, follow-up…, transabdominal approach, per fetus. New concepts for code selection include trimesters in most categories. The disorder usually occurs in the third trimester of pregnancy and worsens over time. I am assuming there was an initial scan, usually reported using codes 76801-76810 Use code 76811 ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation only when all of its elements are performed. A note at the beginning of Chapter 15 defines the timeframes for the three trimesters.