Wiki pregnancy ultrasounds

[LuckyLily]

I would like some guidance on this scenario.

Pregnant woman comes in for ultrasound. On the order it has O26.841 (uterine size date discrepancy). Usually nothing is found abnormal and the final impression would describe the fetal pole. From my understanding you would use the O26.841 for your diagnosis.

Another scenario-On order it has O26.841 and the final impression is- 4mm intrauterine fluid collection possibly representing early gestational sac. correlation with patients laboratory findings recommended.

The coder used these codes-Z34.91 (Encounter for supervision of normal pregnancy) R18.8 (other ascites). Why would the coder use Z34.91 when the physician is concerned about uterine size date discrepancy? Shouldn't the O26.841 code be used?

I'm trying to clarify if the dx on the order should be used when the ultrasound does not have any findings.

 

[chembree]

I would discourage giving the codes vs a statement of why the exam is being performed. AHA Coding Clinic has an article about this, but I do not have it in front of me. If I am understanding correctly it sounds more like you are screening the uterus to see if the size matches the dates? A discrepancy has never been determined?

When the patient is being screened for a condition or a condition is suspected but then ruled out, I tend to use one of the codes below -

Suspected condition, ruled out (see also Observation,suspected)
 amniotic cavity and membraneZ03.71
 cervical shorteningZ03.75
 fetal anomalyZ03.73
 fetal growthZ03.74
 maternal and fetal conditions NECZ03.79
 newborn (see also Observation,newborn,suspected condition ruled out)Z05.9
 oligohydramniosZ03.71
 placental problemZ03.72

antenatal, of mother (see also Encounter,antenatal screening)
• Z36.0 Encounter for antenatal screening for chromosomal anomalies
• Z36.1 Encounter for antenatal screening for raised alphafetoprotein level
• Z36.2 Encounter for other antenatal screening follow-up
• Z36.3 Encounter for antenatal screening for malformation
• Z36.4 Encounter for antenatal screening for fetal growth retardation
• Z36.5 Encounter for antenatal screening for isoimmunization
• Z36.8 Encounter for other antenatal screening
• Z36.81 Encounter for antenatal screening for hydrops fetalis
• Z36.82 Encounter for antenatal screening for nuchal translucency
• Z36.83 Encounter for fetal screening for congenital cardiac abnormalities
• Z36.84 Encounter for antenatal screening for fetal lung maturity
• Z36.85 Encounter for antenatal screening for Streptococcus B
• Z36.86 Encounter for antenatal screening for cervical length
• Z36.87 Encounter for antenatal screening for uncertain dates
• Z36.88 Encounter for antenatal screening for fetal macrosomia
• Z36.89 Encounter for other specified antenatal screening
• Z36.8A Encounter for antenatal screening for other genetic defects
• Z36.9 Encounter for antenatal screening, unspecified