pregnancy coding scenarios

• Code Z79.4, Long -term (current) use of insulin, should also be assigned if the diabetes No family history of ovarian or cervical cancer. Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA, COBGC, and Susan Proctor, RHIT, CCS, CPC, review the relevant coding guidelines for coders who handle coding for these patient encounters. Keep in mind, however, the uterus was not ruptured, and this code has a fairly high relative value unit (RVU of 7.98). Examples of Reporting Antepartum Care Services Relocation of a patient. By Peggy Stilley, CPC, CPC-I, COBGC, ACS-OB. Reports finding a small lump in left breast. This information needs to be captured in the note. During pregnancy, childbirth or the puerperium, when COVID-19 is the reason for admission/encounter, code O98.5 -, Other viral diseases complicating pregnancy, childbirth and the puerperium, should be sequenced as the principal/first-listed diagnosis, and code U07.1, COVID-19, and the appropriate codes for associated manifestation (s) should be assigned as additional diagnoses. Under Pruritis, vulvar that codes to L29.2, ICD-10-CM Has only one generic immunization code, © 2021 Practice Fusion, Inc.  |  Site Map  |  Terms  |  Privacy Policy  These “real world” examples can help you tackle day-to-day coding challenges in your OB/GYN practice. There are different diagnosis codes for each. How much time was spent removing the adhesions before seeing the surgical field? Begin Megacode 2 . Solution: The correct way to code for this depends on how your provider documented the patient’s condition. Over the past 2 days she has not been able to perform usual activities due to her symptoms. ICD-10-CM provides four alternative choices that map to the ICD-9 code 616.10 Vaginitis and vulvovagi nitis, unspecified. Wt: 157 lb., up 2 lb. If there is an “in childbirth” option for the Chapter 15 code, this would be assigned when delivery occurs instead of the trimester of the pregnancy If the patient is admitted to the hospital during one trimester and then discharged after entering a subsequent trimester, the trimester when the condition developed would be selected and NOT the trimester at the time of discharge Thankfully, John sustained only minor abrasions to … Bradycardia. Next, let’s look at some COVID-related scenarios and associated code assignment: Pregnant mother with confirmed COVID-19; Code O98.51_, Other viral diseases complicating pregnancy should be sequenced first followed by code U07.1, COVID-19. Pregnancy Scenarios In groups of four, you will role play the following scenarios. Reports continued fetal movement, no contractions, and no vaginal bleeding. 3 V-Fib. Medical history and review of systems – migraines with many triggers including hormonal changes, stress, and specific foods, otherwise no changes since last prenatal visit. Scenario #5 - CODES Diagnoses (Primary) V25.41 - Surveillance of previously prescribed contraceptive pill 595.9 Cystitis, unspecified V72.31 Routine GYN examination V74.5 Special screening examination for venereal disease V76.2 Screening for malignant neoplasms of cervix (PAP) V72.41 Pregnancy exam or test, negative result 76802-each additional gestation (List separately in addition to code for primary procedure) 76805– Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation Pelvic shows cervical motion tenderness and adnexal tenderness on the right. Z3A.36 36 weeks gestation. • If the patient was previously diagnosed with a high risk this Vaginitis is one of the most common gynecologic conditions encountered in the physician office setting. In the scenario above for this patient with bacterial vaginosis, refraining from intercourse was recommended by this physician. Pain Rx also given. Capture that information as appropriate in your note. With the proliferation of COVID-19 cases, we thought we would put together a quick reference listing of some of the common scenarios that coders have asked about. • add-on code reported in addition to code for the technical service provided. This low risk pregnancy may be billed with a package code if four or more visits were completed before the termination. As there is no indication of previous episodes. Providing a detailed description of the pain characteristics is important as well. Like ICD-9, family history can be captured in ICD-10-CM. CCI does not allow the provider to bill separately for anesthesia. Vaginal exam: Cervix fingertip dilated and 75% effaced. 21 year old female G2P1001 with RLQ abdominal pain1 for the last 6 months. Z23 Encounter for immunization, Index to Diseases for ICD-10-CM under the word itching states “see also Pruritis”. Good luck! In some cases payors reimburse for the retrieval of the Pap smear by the physician, and the screening Pap smear at a specific frequency (e.g., every 2 years). Coding Scenario #1 A fffifteen year old flfemale with her first pregnancy developed placenta previa in her 35th week. As the clinical status for this patient is not known, it does not have right versus left, e.g. Code the dialysis and AV graft by the use of “status codes” (Z codes). Antepartum Care Only – 4 to 6 visits – use CPT code 59425 & 1 unit Antepartum Care Only – 7 or more visits – use CPT code 59426 & 1 unit Postpartum Care Only – use CPT code 59430 Note: For other scenarios, refer to the CPT manual for the correct coding. Approximately one hour of extra operating time was utilized in attempting to dissect the bladder from the uterus. Denies history of STIs. Z87.42 Personal history of other diseases of the female genital tract, 611.72 Lump or mass in breast Encounters for patients who are pregnant, in delivery, or in the puerperium, use codes from Chapter 15 Pregnancy, Childbirth and the Puerperium (O00-O9A). She first noticed symptoms about 1 ½ weeks ago. ICD-9-CM Diagnosis Codes Patient admits to a history of alcohol dependence2. Bookmark the Centers for Medicare & Medicaid Services’ (CMS) website in your “favorites” menu, and be aware of local coverage determinations (LCDs) for your Medicare payer. Abdominal pain that will not go away and irregular menses. Long time history migraine headaches. LMP was 4 months ago. As patient history and circumstances will vary, these brief scenarios are illustrative in nature and should not be strictly interpreted or used as documentation and coding guidelines. For example, an obstetrics office could bill CPT code 59400 to cover office visits, a vaginal delivery, and postpartum care, as opposed to separate codes for individual visits or separately billing the antepartum period, delivery, and postpartum period. Identifying the specific area of abdominal pain is important, as some payers may deny claims with “unspecified” codes. If the doctor’s documentation had just documented, “positive pregnancy test,” the code would be Z32.01, Encounter for pregnancy test, result positive. The Canadian Institute for Health Information (CIHI) is an independent, not-for-profit organization that provides essential information on … Inside, there are key data points and specific guidelines that must be followed at all times. Begin Megacode 4 . 3. Code the following scenario according to ICD-10 coding conventions and guidelines: Jane and John Doe were shopping at the mall the day after Thanksgiving to take advantage of the sales. Should I use E11.69 or E11.29? Code the following scenario according to ICD-10 coding conventions and guidelines: Due to ailing health, Jane?s grandfather will be moving in with her in a few months. These “real world” examples can help you tackle day-to-day coding challenges in your OB/GYN practice. For example, the physician’s documentation might specify: “There were dense adhesions from the bladder to the uterus appearing to have grown to the patient’s uterus from a prior cesarean. No history of STD. Overall, global billing for maternity eases the burden for both patient and provider. Similarly to ICD-9, ICD-10 describes preeclampsia as a complication of pregnancy which is characterized by hypertension; proteinuria and edema may also be present. Review of systems negative except as noted above. As with all coding, coders should follow Official Guidelines for Coding and Reporting and the COVD-19 Frequently Asked Questions document by the AHA. We are looking for thought leaders to contribute content to AAPC’s Knowledge Center. Begin Megacode 3 . 1 V-Tach. O99.89 Pregnancy, complicated by disorder of specified body system She is in a new monogamous relationship with male partner x 5 weeks, sexually active with protection. G43.9Ø9 Migraine, unspecified, not intractable w/o status migrainosus Patient states she tried to self-treat using an over-the-counter yeast preparation approximately 1 week ago without relief of symptoms. Z15.01 Genetic susceptibility to malignant neoplasm of breast, 642.43 Mild or unspecified preeclampsia, antepartum condition or complication 789.03 Abdominal pain, right lower quadrant Explained treatment plan and purpose for admission to patient and husband. Pelvic: External exam-vulvar redness, no vulvar edema and no adherent white clumps present; Speculum exam – vaginal walls pink, cervix intact, closed os, thin gray and foul smelling discharge noted in vaginal canal. The rationale for abnormal findings in this encounter is based on the presence of the breast lump. Instructed patient to avoid douching and use of bubble bath products. 346.90 Migraine, w/o mention of intractable or status migrainosus, O14.Ø3 Mild to moderate preeclampsia, third trimester Left breast examined normal except for 1.5cm mass on left lower/outer quadrant5. For example, the following codes are provided for category O25, Malnutrition in pregnancy, childbirth and the puerperium: O25.1, Malnutrition in pregnancy; O25.10, Malnutrition in pregnancy, unspecified trimester; O25.11, Malnutrition in pregnancy, first trimester; O25.12, …

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