Wiki Delivery diagnosis

[kathleenl]

Good morning,
We are having some differences in opinion regarding where to find dx codes for deliveries. The example below is what is on the C-section report:
Cesarean section procedure note
Date xx/xx/xx
Surgeon - Dr. X
Assistant - Dr. Y
Preoperative diagnosis:
-SIUP at 39w 2d
Elective primary cesarean section for patient
Postoperative diagnosis:
-Same
Procedure performed
Primary low transverse cesarean section

The report then goes on to describe the anesthesia, findings, risks, and the description of the c section. There are no complications, all is well, baby is fine etc..
-Some co-workers will go in to this patients OB record or the admission note, to see if there are any other diagnosis that may apply, for example if the patient has gestational dm or htn(for example).
-Some say to just use what is on the procedure note.
Are there any documentation guidelines regarding this? I am inclined to think that we would use what is on the procedure note and that the OB's might need to be in serviced about what needs to be listed on there..
Any help in locating the guidelines is appreciated!
Happy Thanksgiving!
-Kathleen

 

[ahguzman]

You "should" code what the provider has documented on the operative report, however you should query the provider if there are documentation discrepancies and request an addendum with corrections if needed. How proactive does your organization/employer want you to be?

 

[kathleenl]

You "should" code what the provider has documented on the operative report, however you should query the provider if there are documentation discrepancies and request an addendum with corrections if needed. How proactive does your organization/employer want you to be?

Thanks, unless I search, I wouldn't know if there is a discrepancy or not, that's part of the issue. They really do not want us to go searching for info, it should be on the report itself.