Bernadette10
Guru
Should Z98.891 be coded for the postpartum C section scar? To me it sounds like a history of a scar from a previous C section, not the current most recent one, so I didn't think it should be coded but am not sure.
Patient presents for 6-week postpartum followup.
S/p elective RLTCS
Patient has no complaints.
She is not breast-feeding and is not experiencing problems.
Her postpartum period was complicated with recurrent postpartum preeclampsia for which she received magnesium sulfate infusion
She was maintained on Procardia XL 30 mg daily.
She reports compliance with her medication.
Review of her BP shows BP range in the mild/stage 1 hypertension
Denies headaches/visual changes/RUQ pain/nausea/vomiting
Patient denies any symptoms of depression. no suicidal nor homicidal ideation
Patient has had irregular periods for most of her life. She voices her desire to resume her OCP to regulate her periods.
She currently uses no method for contraception.
Assessment/Plan
1. Routine postpartum follow-up Z39.2
- Normal exam
2. S/P cesarean section Z98.891?
3. Hypertension O16.5
- Amb referral to Primary Care Physician
- Discussed with the patient increased likelihood of progression to chronic hypertension
- Reestablish care with PCP for BP monitoring and management
4. Irregular periods O99.893, N92.6, Z30.011
- drospirenone-ethinyl estradioL (YAZ) 3-0.02 mg per tablet; Take 1 tablet by mouth daily for 180 days. Dispense: 28 tablet; Refill: 11
Return in about 1 year (around 6/17/2023).
Patient presents for 6-week postpartum followup.
S/p elective RLTCS
Patient has no complaints.
She is not breast-feeding and is not experiencing problems.
Her postpartum period was complicated with recurrent postpartum preeclampsia for which she received magnesium sulfate infusion
She was maintained on Procardia XL 30 mg daily.
She reports compliance with her medication.
Review of her BP shows BP range in the mild/stage 1 hypertension
Denies headaches/visual changes/RUQ pain/nausea/vomiting
Patient denies any symptoms of depression. no suicidal nor homicidal ideation
Patient has had irregular periods for most of her life. She voices her desire to resume her OCP to regulate her periods.
She currently uses no method for contraception.
Assessment/Plan
1. Routine postpartum follow-up Z39.2
- Normal exam
2. S/P cesarean section Z98.891?
3. Hypertension O16.5
- Amb referral to Primary Care Physician
- Discussed with the patient increased likelihood of progression to chronic hypertension
- Reestablish care with PCP for BP monitoring and management
4. Irregular periods O99.893, N92.6, Z30.011
- drospirenone-ethinyl estradioL (YAZ) 3-0.02 mg per tablet; Take 1 tablet by mouth daily for 180 days. Dispense: 28 tablet; Refill: 11
Return in about 1 year (around 6/17/2023).
