Help with Dx code

calicoder10

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Patient who is pregnant (confirmed by her OB with positive HCG) comes to the ED requesting a US "to check" on her pregnancy. She has no complaint. Can I use Z01.89?

Thanks
 
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:confused: What was actually done by the ED providers?

Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings
Z32.0X Encounter for pregnancy test

I have no idea. I don't understand why she'd go to the ED for this...
 

calicoder10

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Nothing was done. The MD actually "instructed" her that the visits was an inappropriate use of the ED and referred her back to her OB. Check with our QA department and they suggested, Z71.1 Person with feared health complaint in whom no diagnosis is made.
Thanks for the help!
 
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I actually just came upon that code, Z71.1 today and was going to post it but you beat me to it!
 

mitchellde

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If the patient is confirmed pregnant then you must use a pregnancy code. And since this was not a visit to confirm the pregnancy then you would not use the code for the pregnancy test. Also the Z71 for feared complaint would not be appropriate. You should use the pregnancy supervision Z code that fits her status. That is why she was there even if it was inappropriate use of the ER.
 
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If it was the case that the report of pregnancy was made by patient's statement and no confirmation was done while in the ED, then how would it change the coding if all else remained the same in this scenario?
 

mitchellde

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If the patient presented with the possibility of being pregnant but no sure confirmation by medical professional , then the ER provider will perform a gregnancy test and you would use a Z code for the pregnancy test with the corresponding result.
 

calicoder10

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The patient already knew she was pregnant. She just wanted to have a US done to check on how here pregnant was going.
 
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