Wiki office visit unrelated to pregnancy

[ladymatthew]

Hello! looking for a bit of guidance here..... I code for a private practice of orthopedic surgeons and haven't come across this in quite some time, but we had a pregnant patient come into the office for evaluation of a mass on her wrist. It was diagnosed as being a benign soft tissue tumor- I am not as familiar with pregnancy coding and the physician did not state that the pregnancy was incidental to the problem being treated only that her medical history was notable for the fact that she is 5 months pregnant, so my question is how do I report the dx's for this visit? Do I need to report that this is a complication of pregnancy? Or is it acceptable to report the pregnancy status code in this situation? Thank you! any help is greatly appreciated!

-Leah Matthew, CPC

 

[mitchellde]

If the provider does not document that the pregnancy is incidental then you always use the 0 code for pregnancy complicated by, followed by the Z3A code for the weeks of gestation.

 

[ladymatthew]

thank you

If the provider does not document that the pregnancy is incidental then you always use the 0 code for pregnancy complicated by, followed by the Z3A code for the weeks of gestation.

thank you so much! That is what I figured, I just wasn't positive if the MD had to actually state "pregnancy is incidental to reason for this visit". Thank you again!

 

[Fahad.Ogagang@MiraMedGS.com]

coding

code O99.89 for the maternal condition
O99.8 Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium
Conditions in D00-D48, H00-H95, M00-N99, and Q00-Q99
Use additional code to identify condition
the condition is D21.10
and Z3A. code