Coding complications during pregnancy

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I have to admit I'm not real good when coding for pregnancy and complications. Patient went to ER with abdominal pain and is 17 weeks pregnant. I know to code the Z3A.17 as the secondary dx but what about the abdominal pain? Is there a complication code for abdominal pain or do I just use R10.9?

Thanks for any help.
 
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I have to admit I'm not real good when coding for pregnancy and complications. Patient went to ER with abdominal pain and is 17 weeks pregnant. I know to code the Z3A.17 as the secondary dx but what about the abdominal pain? Is there a complication code for abdominal pain or do I just use R10.9?

Thanks for any help.

Is there a documented relationship between the abd pain and the pregnancy? Are there any other diagnoses? If you could provide additional information, that'd be helpful.
 
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Sorry all I have is the patient came through the ER with abdominal pain - there's no mention of injury and nothing to link the abdominal pain with the pregnancy.

Thanks,
 
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You will want to use a code from Chapter 15 as your primary dx, you may want to look at O26.892 to see if that fits your pt's dx, use the Z3A.17 as secondary.
 
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You will want to use a code from Chapter 15 as your primary dx, you may want to look at O26.892 to see if that fits your pt's dx, use the Z3A.17 as secondary.

Actually, that's not correct. If the provider does not document a relationship between the abdominal pain and the pregnancy, you can't assume that complication exists.

With the lack of a documented relationship and no mention of any concerns or complications to the pregnancy, you'd use the appropriate code for the abdominal pain (eg, R10.9) and Z33.1 for incidental pregnancy state. You could liken it to a pregnant patient who comes in with a broken finger.
 
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I thought that if patient is pregnant you would always code from Chapter 15, my understanding is that it is up to the physician to specifically state that the condition is not complicating the pregnancy, without that statement then you cant assume it is not complicating pregnancy. I am not sure if this is correct, and please correct me if I am wrong, but that is what i was taught.
 

mitchellde

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you cannot assume the condition is caused by the pregnancy but you do assume the condition affects the pregnancy. The guidelines indicated the provider must document that the current condition is NOT affecting the pregnancy in order to code the pregnancy as incidental. therefore you will need to go to
O99.89 for other conditions affecting pregnancy
then you would use the R10.9 secondary followed by the Z3A.17.
 

Cmama12

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Actually, that's not correct. If the provider does not document a relationship between the abdominal pain and the pregnancy, you can't assume that complication exists.

With the lack of a documented relationship and no mention of any concerns or complications to the pregnancy, you'd use the appropriate code for the abdominal pain (eg, R10.9) and Z33.1 for incidental pregnancy state. You could liken it to a pregnant patient who comes in with a broken finger.

You need to use a code from chapter 15 unless the doctor specifically documents the pain, broken finger or whatever as being incidental. This is in the Chapter 15 guideline.
 
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