Admitted for other conditions found to have pregnant and underwent abortion

[srinivas.a]

25 yr old female patient with metastatic biliary cancer admitted to inpatient for neoplasm related pain and after 10 days of admission patient suddenly developed severe vaginal bleeding and gyn consultation was done, ordered labs . Labs shows high BHCG levels 1,6770 IU/L. Gyn consultant documents ---found to have pregnant and underwent miscarriage. how would i code this encounter ?

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Anugu Srinivas
Medical Coder
Bachelor of pharmacy,CCS

 

[KellyLR]

Other condition developed after admission

Hi,

Code the neoplastic pain code and metastatic cancer as primary and code the miscarriage as secondary. Assign correct POAs. I would have to see the medical record but since I can't, based on what you documented that is what I would go with using the obstetric codes for neoplasm coding and use the miscarriage code. Guidelines state that after study, if the patient had the condition and was not discovered until after admission, then you can code it based on its presence at admission. G893 O9A119 C7889 K8681 O039 The docx seems a little hinky; meaning patient care would have covered this pregnancy question during routine workup of patient before or during admission checking if pregnant. But, I would code it in this fashion based on what was supplied. Pt ultimately admitted for neoplasm related pain while pregnant and then lost pregnancy.