mchllshrms
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I have a question about something I was told about coding deliveries. I was told that unless the doctor specifically documents the phrase "premature delivery" in his note, that we can't use the diagnosis of premature delivery.
For example, in the op note or delivery note, our hospital uses a system where delivering doctor uses a template for the delivery in which he notates: "Gestational Age: 32w0d" Now, we OB coders know that a delivery before 37 weeks is considered premature.
However, the person I am referring to told me that you cannot just use the notation of 32w0d to code a dx of premature delivery. They said the doctor HAS TO actually notate the phrase "premature delivery" in the note.
I think that the provider documenting 32w0d would be sufficient notation to use the dx code premature delivery. According to guidelines, which is the correct way of thinking?
If you subscribe to this person's way of thinking, then technically, you'd have to do the same for coding post-dates, grand multiparity (i.e. GP7007 notated in the delivery note would not be sufficient, the doc would have to use phrase "grand multiparity") elderly gravida (if the patient's record states that she is 40 years old, the doc would need to actually notate "elderly gravida"), etc.
Thank you and please list an actual reference with your answer!
For example, in the op note or delivery note, our hospital uses a system where delivering doctor uses a template for the delivery in which he notates: "Gestational Age: 32w0d" Now, we OB coders know that a delivery before 37 weeks is considered premature.
However, the person I am referring to told me that you cannot just use the notation of 32w0d to code a dx of premature delivery. They said the doctor HAS TO actually notate the phrase "premature delivery" in the note.
I think that the provider documenting 32w0d would be sufficient notation to use the dx code premature delivery. According to guidelines, which is the correct way of thinking?
If you subscribe to this person's way of thinking, then technically, you'd have to do the same for coding post-dates, grand multiparity (i.e. GP7007 notated in the delivery note would not be sufficient, the doc would have to use phrase "grand multiparity") elderly gravida (if the patient's record states that she is 40 years old, the doc would need to actually notate "elderly gravida"), etc.
Thank you and please list an actual reference with your answer!