Pregnancy diagnosis

calicoder10

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I have a dumb question...A patient is seen in the ED for chest pain. She mentions to the doctor that she is 10 weeks pregnant and had an US showing fetal demise. Do I need to report pregnancy dx?

Thanks
 

calicoder10

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To report Z33.1, the doctor has to document that the current condition is not affecting the pregnancy. There is no documentation from the doctor say that.
Thanks though.
 

mitchellde

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If the documentation indicates that the patient is pregnant then you must use an O code. who diagnosed the fetal demise? and if it was previously diagnosed then is the patient still pregnant? is it a missed AB? there are many questions to be addressed with this.
 

calicoder10

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The MD states "She mentions that she is 10 weeks pregnant and was diagnosed the other day with fetal demise, per US."
 

mitchellde

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How strange that there appears to be no attempt to verify this by contacting the OB. I say use an O code as there is no confirmatory report of a fetal demise. I am not use to a fetal demise waiting even a few days before a scheduled procedure to end the pregnancy. I am assuming there was something done to confirm the pregnancy? if not I would make sure the provider documents the pregnancy as a diagnosis not as a per patient item.
 
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How strange that there appears to be no attempt to verify this by contacting the OB. I say use an O code as there is no confirmatory report of a fetal demise. I am not use to a fetal demise waiting even a few days before a scheduled procedure to end the pregnancy. I am assuming there was something done to confirm the pregnancy? if not I would make sure the provider documents the pregnancy as a diagnosis not as a per patient item.

I agree the pregnancy needs to be reported as long as it was confirmed, which I don't understand why it wouldn't have been. I also agree the fetal demise should not be reported because that's a statement from the patient, not confirmed by the provider. There is also no statement linking the chest pain to the pregnancy, so you shouldn't code it as if it were a complication. As it stands, the chest pain is existing on its own and appears to be the only thing that didn't come from the patient's mouth.

Is there any additional documentation you can provide? As previously mentioned, it's kind of difficult to guide you in the right direction with such little information.
 
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