pregnancy, s/p excision of gluteal cleft mass

tag60

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I can't seem to figure this one out! Scanning down the index under Pregnancy, complicated by...and nothing seems to fit. I'm looking for an O code. This is for a routine OB checkup in which the provider mentions pt had excision of a mass at the ER. Pt being followed by the surgeon, but because provider mentioned it in this visit, I need to code it as a complication of pregnancy, correct?

Per note: Pt is status post surgical excision of her gluteal cleft mass 2 weeks ago. Healing well. Follows with surgeon. Pain still present but better. Area covered with large bandage; not removed, not examined.

Continues with rest of routine OB visit...

Please help me figure out the appropriate O code for this particular diagnosis.

Thanks in advance!
 

CodingKing

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I'm not sure if this is helpful or not

From the ICD-10-CM Guidelines

Codes from chapter 15 and sequencing priority Obstetric cases require codes from chapter 15, codes in the range O00-O9A, Pregnancy, Childbirth, and the Puerperium. Chapter 15 codes have sequencing priority over codes from other chapters. Additional codes from other chapters may be used in conjunction with chapter 15 codes to further specify conditions. Should the provider document that the pregnancy is incidental to the encounter, then code Z33.1, Pregnant state, incidental, should be used in place of any chapter 15 codes. It is the provider’s responsibility to state that the condition being treated is not affecting the pregnancy.
 

tracylc10

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I am not sure that this needs to be coded. Is it complicating the pregnancy? Was it why the patient was being seen? I almost think that if it was not the reason for the visit and it is not complicating he pregnancy, then it really does not need to be coded.
 

tag60

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It has been emphasized on this forum that all conditions in pregnancy are considered complications unless the provider states they are not. That is why I believe I need to code the fact that she had this excision. Provider does address it by mentioning that the pain has gotten better.

Does anyone have a suggestion as to O code? Perhaps something along the lines of "postprocedural state," but again, I just can't find anything when checking the index.

Thank you!
 
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history

isn't this a past medical history? the procedure was done 2 weeks, should be coded as Hx
My code for this if it is a present condition is O99.89 -Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium plus R22.2.
 

CodingKing

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It has been emphasized on this forum that all conditions in pregnancy are considered complications unless the provider states they are not. That is why I believe I need to code the fact that she had this excision. Provider does address it by mentioning that the pain has gotten better.

Does anyone have a suggestion as to O code? Perhaps something along the lines of "postprocedural state," but again, I just can't find anything when checking the index.

Thank you!
You may want to query the physician. They should be more specific when a pregnant patient comes in with a non-pregnancy related issue. Explain to them without this information its automatically considered a complication of pregnancy.
 
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