Inpatient Facility Coding & Compliance Alert

Question: A 36-year-old pregnant female, primigravida, was admitted at 42 weeks of gestation. A low cervical C-section was performed due to breech presentation. The patient required IV antibiotics during labor and delivery for a generalized infection of Group B Streptococcus. The patient desired sterilization, so a bilateral tubal ligation was performed after delivery. How should we code the diagnoses and procedures associated with this admission?

Washington Subscriber Answer: The principal diagnosis will be intrauterine pregnancy, breech presentation (652.21, Breech presentation without version delivered; delivered, with or without mention of antepartum condition) with a secondary diagnosis of post-term pregnancy (645.11, Post term pregnancy delivered with or without antepartum condition; delivered, with or without mention of antepartum condition). Other diagnoses you should include are 041.02 (Streptococcus infection in conditions classified elsewhere and of unspecified site streptococcus group b) and V25.2 (Encounter for contraceptive management; sterilization). The principal procedure [...]