Question about status post deliveries

kparker1980

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Hi,

I have been doing OB/GYN coding and hospital coding for deliveries and surgical procedures for about a year now. I just recently started doing some IM coding, and have an encounter for a patient who is being seen for an annual visit, and delivered 4 months prior. It is noted in the chart that she delivered at 7 months because there was damage to her placenta. The doctor is using code O60.03 for premature labor in third trimester. I know that this is not correct, because the patient is no longer pregnant, and we would need to use a weeks of gestation code. I don't think that using O94 for sequela of pregnancy would be appropriate either, so I am not sure what to do in this case. It also wouldn't be Z33.1 because she is not currently pregnant. Do any of you know what codes we would use to document that a patient was pregnant without using the delivery codes or complication codes? I am thinking that I would just remove it, but I am not 100% sure on that. Any help would be much appreciated.

Kim
 

grothrock

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It sounds like this is just a notation of the premature delivery and not a current issue being treated or no longer present? So wouldn't you just report Z87.51 Personal hx of pre-term labor? If there is a current condition that is associated with the delivery then maybe use O90.89 Other complications of the puerperium NEC? The primary reason for the visit was for the Annual right?
 

kparker1980

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Yes she is here for an annual visit. Thank you this is why sometimes it helps to have an extra set of eyes for things. I am aware of that Z code, I just wasn't thinking of that. Thank you reminding me!!
 
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