JHrabal
New
I'm confused as to how this one should be coded. Physician chose 59409 with O42.012, preterm premature rupture of membranes onset of labor within 24 hours of rupture, second trimester, Z3A.19 19 weeks gestation of pregnancy, and Z37.1 Single stillbirth. I'm thinking 59855 with O02.1 missed abortion. But then I'm questioning that because of the *heartbeat present*, so not really missed abortion?? and delivery codes are for 20 weeks+. Another opinion would be greatly appreciated!
HISTORY OF PRESENT ILLNESS: This is a 35-year-old, gravida 4, para 2, who is currently 19.2 weeks. She was using the bathroom earlier today, and she felt a bulge in her vagina. She came by car, and she states that she had fluid coming out her vagina. Examination revealed that she is dilated to 2 to 3. She has a bulging bag. Ultrasound showed breech presentation. She is 19.2 weeks. Heartbeat present. I have talked to the family, and advised them of the situation, 19 weeks ruptured membranes, the possibility of survival is very, very low, and they agree to be induced.
HEART: Regular rate and rhythm without murmurs or gallops.
ABDOMEN: Fundal height is just below the umbilicus. Ultrasound shows a
breech presentation. Heartbeat is present, bulging sac.
IMPRESSION: Ruptured membranes, cervical incompetence, 19.2 weeks PLAN: We will do Pitocin, possible Cytotec induction.
DATE OF PROCEDURE:
LABOR AND DELIVERY NOTE Premature ruptured membranes at 19 weeks, followed by Cytotec and Pitocin induction. The patient delivered sac, placenta, and fetus in its entirety. Estimated blood loss was approximately 500 mL. No lacerations noted. The patient tolerated the procedure well.
HISTORY OF PRESENT ILLNESS: This is a 35-year-old, gravida 4, para 2, who is currently 19.2 weeks. She was using the bathroom earlier today, and she felt a bulge in her vagina. She came by car, and she states that she had fluid coming out her vagina. Examination revealed that she is dilated to 2 to 3. She has a bulging bag. Ultrasound showed breech presentation. She is 19.2 weeks. Heartbeat present. I have talked to the family, and advised them of the situation, 19 weeks ruptured membranes, the possibility of survival is very, very low, and they agree to be induced.
HEART: Regular rate and rhythm without murmurs or gallops.
ABDOMEN: Fundal height is just below the umbilicus. Ultrasound shows a
breech presentation. Heartbeat is present, bulging sac.
IMPRESSION: Ruptured membranes, cervical incompetence, 19.2 weeks PLAN: We will do Pitocin, possible Cytotec induction.
DATE OF PROCEDURE:
LABOR AND DELIVERY NOTE Premature ruptured membranes at 19 weeks, followed by Cytotec and Pitocin induction. The patient delivered sac, placenta, and fetus in its entirety. Estimated blood loss was approximately 500 mL. No lacerations noted. The patient tolerated the procedure well.