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What is considered clear documentation for coding ABO and Rh incompatibility? Does the MD have to give the blood types and/or state Coombs positive or negative test results? When do you assign the P55.0, P55.1 and R74.89
Second day for newborn state Coombs positive.
Then on discharge documentation has the following:
Newborn course significant for coombs +, bili wnl. Infants breastfeeding improved overnight, previously shallow latching with assistance from lactation is now latching more effectively.
Vitals have remained within normal limits. Newborn exam remains benign. Overall, baby is feeding, voiding and stooling appropriately, and has been deemed stable for discharge to home. Bili 6.6 at 24hrs.
ASSESSMENT: post term female, ABO Incompatibility of Newborn without jaundice
What is considered clear documentation for coding ABO and Rh incompatibility? Does the MD have to give the blood types and/or state Coombs positive or negative test results? When do you assign the P55.0, P55.1 and R74.89
Second day for newborn state Coombs positive.
Then on discharge documentation has the following:
Newborn course significant for coombs +, bili wnl. Infants breastfeeding improved overnight, previously shallow latching with assistance from lactation is now latching more effectively.
Vitals have remained within normal limits. Newborn exam remains benign. Overall, baby is feeding, voiding and stooling appropriately, and has been deemed stable for discharge to home. Bili 6.6 at 24hrs.
ASSESSMENT: post term female, ABO Incompatibility of Newborn without jaundice