Wiki Group B Streptococcus Bacteriuria

[merandacancilla]

Hi Everyone: I am new to coding OBGYN and am looking for some guidance on coding of GBS Bacteriuria in a pregnant patient.

I don't have a whole lot of information to go on from the note.

Visit Notes:
Pt Denies LOF, VB. Reports GFM and having CTX but nothing worth timing. Also having lots more swelling in her feet, ankle's, and legs she is very concerned with the swelling and high blood pressures. GBS needs done today. Overall feeling ok. Labs were completed and WNL for GHTN. Plan for IOL- scheduled for 37 weeks.

A/P:
(1) 36 weeks gestation of pregnancy:
Z3A.36 - 36 weeks gestation of pregnancy
(2) Gestational [pregnancy-induced] hypertension without significant proteinuria, third trimester:
O13.3 - Gestational [pregnancy-induced] hypertension without significant proteinuria, third trimester
(3) Group B streptococcal bacteriuria:
R82.71 - Bacteriuria
I don't think R82.71 is the correct code for this.

I was thinking Z22.330-Carrier of Group B Streptococcus

or maybe

O99.820- Streptococcus B carrier state complicating pregnancy

I did query the provider and she suggested B95.1- Streptococcus, group B, as the cause of diseases classified elsewhere

It doesn't say this is an active Urinary Tract Infection anywhere in the note so I am hesitant to use O23.43- Unspecified infection of urinary tract in pregnancy, third trimester

Any help would be greatly appreciated!

 

[natashalage]

Hello, I am new to OBGYN. I would use O99.820 because we have O-code for it and that would be preference + maybe O99.89- (don't remember exactly. Other conditions in childbirth) with R82.71.
2. search this topic in OBGYN forum, I remember someone was discussing this topic.
3. Coding Clinic had the answer to GBS in pregnancy. If I find it, I will post it.

 

[nielynco]

Hi Everyone: I am new to coding OBGYN and am looking for some guidance on coding of GBS Bacteriuria in a pregnant patient.

I don't have a whole lot of information to go on from the note.

Visit Notes:
Pt Denies LOF, VB. Reports GFM and having CTX but nothing worth timing. Also having lots more swelling in her feet, ankle's, and legs she is very concerned with the swelling and high blood pressures. GBS needs done today. Overall feeling ok. Labs were completed and WNL for GHTN. Plan for IOL- scheduled for 37 weeks.

A/P:
(1) 36 weeks gestation of pregnancy:
Z3A.36 - 36 weeks gestation of pregnancy
(2) Gestational [pregnancy-induced] hypertension without significant proteinuria, third trimester:
O13.3 - Gestational [pregnancy-induced] hypertension without significant proteinuria, third trimester
(3) Group B streptococcal bacteriuria:
R82.71 - Bacteriuria
I don't think R82.71 is the correct code for this.

I was thinking Z22.330-Carrier of Group B Streptococcus

or maybe

O99.820- Streptococcus B carrier state complicating pregnancy

I did query the provider and she suggested B95.1- Streptococcus, group B, as the cause of diseases classified elsewhere

It doesn't say this is an active Urinary Tract Infection anywhere in the note so I am hesitant to use O23.43- Unspecified infection of urinary tract in pregnancy, third trimester

Any help would be greatly appreciated!

Okay, my take on this note is that the provider is ordering a GBS screening, not that the patient has tested positive for GBS. I also see no information that the patient currently has a UTI due to GBS or any other bacterium. And you would only use a code for carrier state if she has confirmed GBS but has no symptoms but could pass it on to someone else. In the case of it being in the urine, it is a danger to the mother most often, not the fetus (which would not be the case if the GBS was present in the vagina or rectum and could be pass on to the baby at birth). The B code can only be used as a secondary code to the primary (which could be R82.71 if she was not pregnant) or to O23.43 if she has a confirmed urinary tract infection. As she is pregnant and you do not know based on this note her GBS status, you could not report O99.820 either. So, you can go back to the record or the provider and get more information as to the patient's status at the time of this visit. The note does say labs done and within normal limits. If you are trying to find a diagnosis to order the GBS screening, you should report Z36.85, Encounter for antenatal screening for Streptococcus B

 

[merandacancilla]

Okay, my take on this note is that the provider is ordering a GBS screening, not that the patient has tested positive for GBS. I also see no information that the patient currently has a UTI due to GBS or any other bacterium. And you would only use a code for carrier state if she has confirmed GBS but has no symptoms but could pass it on to someone else. In the case of it being in the urine, it is a danger to the mother most often, not the fetus (which would not be the case if the GBS was present in the vagina or rectum and could be pass on to the baby at birth). The B code can only be used as a secondary code to the primary (which could be R82.71 if she was not pregnant) or to O23.43 if she has a confirmed urinary tract infection. As she is pregnant and you do not know based on this note her GBS status, you could not report O99.820 either. So, you can go back to the record or the provider and get more information as to the patient's status at the time of this visit. The note does say labs done and within normal limits. If you are trying to find a diagnosis to order the GBS screening, you should report Z36.85, Encounter for antenatal screening for Streptococcus B

Thank you so much for the help!
I went back to the chart and looked for the GBS Screen result and it was negative.
She did have a urine approximately a month before this visit that showed 2+ Bacteria so I am assuming that is where the R82.71 for the Bacteriuria came from.
In this case should I use R82.71 or is there a Pregnancy specific diagnosis code that I should use?
Maybe O28.8-
Other abnormal findings on antenatal screening of mother?

 

[nielynco]

Thank you so much for the help!
I went back to the chart and looked for the GBS Screen result and it was negative.
She did have a urine approximately a month before this visit that showed 2+ Bacteria so I am assuming that is where the R82.71 for the Bacteriuria came from.
In this case should I use R82.71 or is there a Pregnancy specific diagnosis code that I should use?
Maybe O28.8-
Other abnormal findings on antenatal screening of mother?

Was she being treated or tested for this infection at this visit? If not, I would not report it.