gestational edema?

tag60

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Pt is in for routine OB checkup. Assessment: "Mild dependent edema at 31 weeks, improved from last visit."

Do I code this as "gestational edema," O12.03, or must the provider state that it is "gestational edema"? Sorry if this is a dumb question, but I am unsure if provider has to state it as such (gestational).

Otherwise I could code as O26.893, other specified pregnancy related conditions and R60.9 (or R60.0 as it is edema of ankles).

Thanks in advance!
 
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I would query the provider. I would assume it's pregnancy-related but the documentation has to make that connection... that the pregnancy caused the edema. It's all a matter of whether or not the edema is a complication. If it were me, based just off what you've posted, I wouldn't code as gestational because making the leap to a complication code is a bit too far for me.
 
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