Wiki Can a diagnosis discussed in the H&P documentation be used on the delivery?

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cubbiecatz

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Or does the provider have to include it on the delivery note? For example a doctor will mention in the H&P that patient has gestational diabetes but on the delivery note no mention is made.
Does the provider need to add it to the delivery note before we can bill that diagnosis?

Another example, a provider noted in H&P that the reason for cesarean section was due to the baby having intermittent late decelerations of the baby with the head remaining at 0 station for a little under 10 hours. The delivery note the only documentation is due to fetal intolerance of labor.

Thank you, Cathy Satkus
CPC, COBGC
Saint Francis Health System
 
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cubbiecatz said:
Or does the provider have to include it on the delivery note? For example a doctor will mention in the H&P that patient has gestational diabetes but on the delivery note no mention is made.
Does the provider need to add it to the delivery note before we can bill that diagnosis?

Another example, a provider noted in H&P that the reason for cesarean section was due to the baby having intermittent late decelerations of the baby with the head remaining at 0 station for a little under 10 hours. The delivery note the only documentation is due to fetal intolerance of labor.

Thank you, Cathy Satkus
CPC, COBGC
Saint Francis Health System
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Sounds like a provider teaching moment. Frequently you only get the delivery note to code from or that may be the only documentation requested in support of the delivery - treat it like any other op note: it should clearly state the reason for the cesarean or the possible complications affecting the delivery.
 
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Hi Cathy, agree it is frustrating when useful dx aren't in the delivery note. We have been told that we can only pull from the delivery note, unless they have a statement referring you back to the H+P. If I find an example of one like that, I will come back and add it.
 
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Cmama12 said:
Hi Cathy, agree it is frustrating when useful dx aren't in the delivery note. We have been told that we can only pull from the delivery note, unless they have a statement referring you back to the H+P. If I find an example of one like that, I will come back and add it.
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This is very confusing because ACOG, icd-10 and some payer sites say to code the reason for admission on the delivery. So can we only code the reason for admission if they carry it forward to the op note? Acog states the admission is bundled to delivery so seams like we should be able to code from the admission note.
 
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We typically code from the discharge summary, history and physical, physician order/admit note, the anesthesia record, along with the delivery note. Official Coding Guidelines for ICD-10-CM says when a delivery occurs, in cases of cesarean delivery, if the patient was admitted with a condition that resulted in the performance of a cesarean delivery, that condition should be selected as a principal diagnosis. There is more to the guidelines than that but it is long. Do physician offices have different guidelines than hospitals?
 
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LoriAnn50 said:
We typically code from the discharge summary, history and physical, physician order/admit note, the anesthesia record, along with the delivery note. Official Coding Guidelines for ICD-10-CM says when a delivery occurs, in cases of cesarean delivery, if the patient was admitted with a condition that resulted in the performance of a cesarean delivery, that condition should be selected as a principal diagnosis. There is more to the guidelines than that but it is long. Do physician offices have different guidelines than hospitals?
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ICD-10-CM guidelines specify the rules for outpatient coding as well for inpatient coding. For outpatient coding guidelines go to Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services of the guidelines. In the opening paragraph of this section it states:

In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis. In determining the first-listed diagnosis the coding conventions of ICD-10-CM, as well as the general and disease specific guidelines take precedence over the outpatient guidelines.
Diagnoses often are not established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is confirmed.
 
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