Wiki Help with Delivery

[tblmt1966]

Patient was admitted for Serve Pre-eclampsia and was inducted for vaginal delivery. Due to category 3 tracing developed an urgent c-section was performed.
Per the C-section report documented the operative diagnosis as 1. Preeclampsia, sever with worsening features. 2. Fetal growth restriction 3. Category 3 tracing.

In the procedure detail the provider documented I was called by RB to evaluate patient due to minimal variability with intermitted decelerations and no cervical progress and on 20 mu/min Pitocin. Patient was evaluated at beside and cervical exam 3/70/-2, head well applied to cervix. AROM for clear fluid. IUPC inserted, FSE inserted without difficulty. Fetal heart was absent variability with Variable decelerations which did not improve with position changes and maternal resuscitative measures. The decision to proceed with stat C-section was made.

My primary code would be the Category 3 tracing. This is my first-time coding this diagnosis and I am unable to find the correct code. The provider gave code of O77.9 my gut is stating that is incorrect as this unspecified code. Can anyone assist me with more specified code for this?

 

[Cmama12]

Patient was admitted for Serve Pre-eclampsia and was inducted for vaginal delivery. Due to category 3 tracing developed an urgent c-section was performed.
Per the C-section report documented the operative diagnosis as 1. Preeclampsia, sever with worsening features. 2. Fetal growth restriction 3. Category 3 tracing.

In the procedure detail the provider documented I was called by RB to evaluate patient due to minimal variability with intermitted decelerations and no cervical progress and on 20 mu/min Pitocin. Patient was evaluated at beside and cervical exam 3/70/-2, head well applied to cervix. AROM for clear fluid. IUPC inserted, FSE inserted without difficulty. Fetal heart was absent variability with Variable decelerations which did not improve with position changes and maternal resuscitative measures. The decision to proceed with stat C-section was made.

My primary code would be the Category 3 tracing. This is my first-time coding this diagnosis and I am unable to find the correct code. The provider gave code of O77.9 my gut is stating that is incorrect as this unspecified code. Can anyone assist me with more specified code for this?

Hi, Please see Ch 15 guidelines, b. Selection of OB principal or first listed diagnosis #4.. Your primary dx is always the reason for admission, so in this case the severe pre-clampsia would be Dx 1. For a cat 3 tracing, the dx would be O76. This would be dx 2, followed by the PFG.

 

[bgrasson]

Hi, Please see Ch 15 guidelines, b. Selection of OB principal or first listed diagnosis #4.. Your primary dx is always the reason for admission, so in this case the severe pre-clampsia would be Dx 1. For a cat 3 tracing, the dx would be O76. This would be dx 2, followed by the PFG.

In this case they proceeded with a c section so shouldn't the reason for c section be listed first? the admission was for pre eclampsia not cat 3 tracing- if i am reading the guidelines correctly?

 

[Cmama12]

In this case they proceeded with a c section so shouldn't the reason for c section be listed first? the admission was for pre eclampsia not cat 3 tracing- if i am reading the guidelines correctly?

No. The guidelines state:

When an obstetric patient is admitted and delivers during that admission, the condition that prompted the admission should be sequenced as the principal diagnosis. If multiple conditions prompted the admission, sequence the one most related to the delivery as the principal diagnosis. A code for any complication of the delivery should be assigned as an additional diagnosis. In cases of cesarean delivery, if the patient was admitted with a condition that resulted in the performance of a cesarean procedure, that condition should be selected as the principal diagnosis. If the reason for the admission was unrelated to the condition resulting in the cesarean delivery, the condition related to the reason for the admission should be selected as the principal diagnosis

In the above case only one reason for admission is stated - the pre-eclampsia. Then the category 3 tracing lead the the c-section. The pre-eclampsia is still first listed per last line in the guidelines.

 

[therese6841]

No. The guidelines state:

When an obstetric patient is admitted and delivers during that admission, the condition that prompted the admission should be sequenced as the principal diagnosis. If multiple conditions prompted the admission, sequence the one most related to the delivery as the principal diagnosis. A code for any complication of the delivery should be assigned as an additional diagnosis. In cases of cesarean delivery, if the patient was admitted with a condition that resulted in the performance of a cesarean procedure, that condition should be selected as the principal diagnosis. If the reason for the admission was unrelated to the condition resulting in the cesarean delivery, the condition related to the reason for the admission should be selected as the principal diagnosis

In the above case only one reason for admission is stated - the pre-eclampsia. Then the category 3 tracing lead the the c-section. The pre-eclampsia is still first listed per last line in the guidelines.

I am getting kick back from the uppers. They are telling me the delivery note needs to stand alone but I am trying to explain the global OB delivery codes are different because they include parental and postpartum care and even the H&P. I showed them that ACOG, ind-10, CMS and even some payers state they want the reason for admission unless there is a reason for c-sect code. I don’t know how to convince them. Do you code from the H&P? Or do your doctors put the reason for admission on the op note? A lot of times my docs dont

 

[Cmama12]

I am getting kick back from the uppers. They are telling me the delivery note needs to stand alone but I am trying to explain the global OB delivery codes are different because they include parental and postpartum care and even the H&P. I showed them that ACOG, ind-10, CMS and even some payers state they want the reason for admission unless there is a reason for c-sect code. I don’t know how to convince them. Do you code from the H&P? Or do your doctors put the reason for admission on the op note? A lot of times my docs dont

The delivery note really should stand alone . Even if you are coding a global code at the time of delivery, you are not pulling information from other places. Some doctors are very detailed and put all the info in their notes; others have the bare minimum. You can encourage them to add it, but if the reason for admission is not in the note, you code what's there.