Our midwife did the delivery, and our physician did 3a laceration repair. Unfortunately, the provider did not provide the dimensions of repair. So, my question is can I code the vagina delivery under the midwife can add modifier 22? My other question is on the diagnosis. This is what I came up with O13.0 O70.21 O72.1 O99.893, R00.0, Z86.19, Z3A.37 Z37.0.
L&D Delivery Note - , CNM - 03/02/2024 2:40 PM EST
Gestational Age at delivery: 37w6d
Admission for: Blood Pressure Check; IOL for GHTN
Labor Complications: gHTN
Pregnancy Problem list:
Patient Active Problem List
Diagnosis Date Noted
Bacterial vaginosis in pregnancy 02/07/2024
Formatting of this note might be different from the original.
Dx 1/29/24
Candidiasis of vagina during pregnancy 02/07/2024
Formatting of this note might be different from the original.
Dx: 1/29/24
Urinary tract infection in mother during pregnancy 12/29/2023
Formatting of this note might be different from the original.
>100K GBS Bayfront 12/24. Rx Amp, needs TOC GBS 10-49000 and IP GBS tx
Formatting of this note might be different from the original.
12/24: >100K, tx sent plan IP tx
Repeat ur Cx: GBS 10-49000 on 1/11/24
HSV-2 infection complicating pregnancy, third trimester 12/25/2023
Formatting of this note might be different from the original.
Initial outbreak 27 weeks, presumed and tx sent by ER. Swab not obtained until day 4 of s/sx - consider accuracy.
1/11/23- Pt reports no active lesions
Will have pt complete treatment for viral suppression at 36 weeks
Anemia complicating pregnancy in third trimester 12/13/2023
Formatting of this note might be different from the original.
Hgb 8.9 at 26w Rx Fe sent and hematology referral placed
Sickle cell trait (CMS/HCC) 10/04/2023
Formatting of this note might be different from the original.
Urine culture q trimester
Mom progressed to complete dilation and pushed effectively, the fetal head was delivered atraumatically, no nuchal noted. The fetal body was delivered atraumatically, with minimal respiratory effort initially Male infant, viable, was delivered. The neonate was placed on the maternal abdomen for skin to skin, that was deferred due to infant acuity Delayed cord clamping x 30secs, followed by double clamp by , CNM, cut by FOB. The placenta was delivered spontaneously and noted to be intact. Fundal massage performed and fundus found to be firm. Bleeding was moderate. IV access was lost at this time. IM methergine and pitocin given. Perineum, vagina, cervix were inspected, and 3a laceration was identified.
See addendum for repair details.
Dr. D DO counseled patient on possible need for blood transfusion.
Newborn sent to NICU for observation due to primary HSV outbreak at 27wks pregnant
Estimated Blood Loss: 1200 mL
Anesthesia: Epidural
APGARs: 7/7
Neonatal Weight: 3380g
Labor Events
Preterm labor?: No
Antenatal steroids?: None
Antibiotics during labor?: Yes
Sac identifier: Sac 1
Rupture date/time: 3/2/2024 1056
Rupture type: Artificial
Fluid color: Clear
Fluid odor: Normal
Labor type: Spontaneous Onset of Labor
Labor allowed to proceed with plans for an attempted vaginal birth?: Yes
Augmentation: Oxytocin, AROM
Augmentation date/time: 3/1/2024 2214
Augmentation indications: Ineffective Contraction Pattern
Complications: None
Newborn Delivery
Time head delivered: 3/2/2024 12:22:44
Birth date/time: 3/2/2024 12:22:52
Delivery type: Vaginal, Spontaneous
Complications: None
Delivery Providers
Delivering clinician: CNM
Placenta
Placenta delivery date/time: 3/2/2024 1228
Placenta removal: Spontaneous
Placenta appearance: Intact
Placenta disposition: pathology
Lacerations
Episiotomy: None
Perineal laceration: 3rd
Perineal laceration repaired?: Yes
Periurethral laceration?: Yes
Periurethral laceration location: right
Periurethral laceration repaired?: Yes
Labial laceration?: Yes
Labial laceration location: left
Labial laceration repaired?: Yes
Vaginal delivery est. blood loss (mL): 1200
Repair suture: 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl
Number of repair packets: 10
CNM
Electronically signed by, CNM at 03/02/2024
Formatting of this note might be different from the original.
Vaginal laceration repair note:
Called to room to evaluate laceration. Had chief resident Dr H assist. 3a laceration noted with minimal involvement of the external anal sphincter capsule. Repaired the anal sphincter capsule in interrupted stitches using 2-0 vicryl. At this time, pt was started to be more uncomfortable and required redosing the epidural. I was called away for an emergency procedure with the chief resident and had Dr B remain to complete the repair. When I returned, there was a signficant remaining amount to complete as the patient was not tolerating the procedure despite multiple epidural boluses and one dose of IV fentanyl as well as local infiltration of lidocaine.
Anesthesia was called as we were considering completing the repair in the OR. They decided to redose the epidural with precedex as well as give IV fentanyl. Pt was comfortable at this time. The deep tissue was brought together with 2-0 vicryl and then the sulcus laceration was repaired as well. There was a left labial laceration which was repaired with 3-0 vicryl. The right periurethral laceration was repaired with 4-0 vicryl in a running fashion. A bimanual was performed and the fundus was firm. Some oozing was noted from the periurethral lac and another interrupted was placed. Final inspection shows no further lacerations. A vaginal packing was placed as well as a foley catheter.
Pt tolerated the remainder of the procedure well
EBL 1200cc, CBC collected
Electronically signed by DO at 03/02/2024 5:12 PM EST
CNM - 03/02/2024 4:47 PM EST
Formatting of this note might be different from the original.
Postpartum patient following PPH of 1200mL and chronic anemia prior to delivery.
Currently tachycardic, HR ranging 110s-120s. Denies dizziness, burred vision, SOB.
Discussed updated hgb 7.7
Discussed at length possible need for blood transfusion due to tachycardia and EBL.
Patient desires blood transfusion now.
1unit PRBC ordered. Dr. DO consulted and aware of patient's status.
Electronically signed by CNM at 03/02/2024
L&D Delivery Note - , CNM - 03/02/2024 2:40 PM EST
Gestational Age at delivery: 37w6d
Admission for: Blood Pressure Check; IOL for GHTN
Labor Complications: gHTN
Pregnancy Problem list:
Patient Active Problem List
Diagnosis Date Noted
Bacterial vaginosis in pregnancy 02/07/2024
Formatting of this note might be different from the original.
Dx 1/29/24
Candidiasis of vagina during pregnancy 02/07/2024
Formatting of this note might be different from the original.
Dx: 1/29/24
Urinary tract infection in mother during pregnancy 12/29/2023
Formatting of this note might be different from the original.
>100K GBS Bayfront 12/24. Rx Amp, needs TOC GBS 10-49000 and IP GBS tx
Formatting of this note might be different from the original.
12/24: >100K, tx sent plan IP tx
Repeat ur Cx: GBS 10-49000 on 1/11/24
HSV-2 infection complicating pregnancy, third trimester 12/25/2023
Formatting of this note might be different from the original.
Initial outbreak 27 weeks, presumed and tx sent by ER. Swab not obtained until day 4 of s/sx - consider accuracy.
1/11/23- Pt reports no active lesions
Will have pt complete treatment for viral suppression at 36 weeks
Anemia complicating pregnancy in third trimester 12/13/2023
Formatting of this note might be different from the original.
Hgb 8.9 at 26w Rx Fe sent and hematology referral placed
Sickle cell trait (CMS/HCC) 10/04/2023
Formatting of this note might be different from the original.
Urine culture q trimester
Mom progressed to complete dilation and pushed effectively, the fetal head was delivered atraumatically, no nuchal noted. The fetal body was delivered atraumatically, with minimal respiratory effort initially Male infant, viable, was delivered. The neonate was placed on the maternal abdomen for skin to skin, that was deferred due to infant acuity Delayed cord clamping x 30secs, followed by double clamp by , CNM, cut by FOB. The placenta was delivered spontaneously and noted to be intact. Fundal massage performed and fundus found to be firm. Bleeding was moderate. IV access was lost at this time. IM methergine and pitocin given. Perineum, vagina, cervix were inspected, and 3a laceration was identified.
See addendum for repair details.
Dr. D DO counseled patient on possible need for blood transfusion.
Newborn sent to NICU for observation due to primary HSV outbreak at 27wks pregnant
Estimated Blood Loss: 1200 mL
Anesthesia: Epidural
APGARs: 7/7
Neonatal Weight: 3380g
Labor Events
Preterm labor?: No
Antenatal steroids?: None
Antibiotics during labor?: Yes
Sac identifier: Sac 1
Rupture date/time: 3/2/2024 1056
Rupture type: Artificial
Fluid color: Clear
Fluid odor: Normal
Labor type: Spontaneous Onset of Labor
Labor allowed to proceed with plans for an attempted vaginal birth?: Yes
Augmentation: Oxytocin, AROM
Augmentation date/time: 3/1/2024 2214
Augmentation indications: Ineffective Contraction Pattern
Complications: None
Newborn Delivery
Time head delivered: 3/2/2024 12:22:44
Birth date/time: 3/2/2024 12:22:52
Delivery type: Vaginal, Spontaneous
Complications: None
Delivery Providers
Delivering clinician: CNM
Placenta
Placenta delivery date/time: 3/2/2024 1228
Placenta removal: Spontaneous
Placenta appearance: Intact
Placenta disposition: pathology
Lacerations
Episiotomy: None
Perineal laceration: 3rd
Perineal laceration repaired?: Yes
Periurethral laceration?: Yes
Periurethral laceration location: right
Periurethral laceration repaired?: Yes
Labial laceration?: Yes
Labial laceration location: left
Labial laceration repaired?: Yes
Vaginal delivery est. blood loss (mL): 1200
Repair suture: 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl
Number of repair packets: 10
CNM
Electronically signed by, CNM at 03/02/2024
Formatting of this note might be different from the original.
Vaginal laceration repair note:
Called to room to evaluate laceration. Had chief resident Dr H assist. 3a laceration noted with minimal involvement of the external anal sphincter capsule. Repaired the anal sphincter capsule in interrupted stitches using 2-0 vicryl. At this time, pt was started to be more uncomfortable and required redosing the epidural. I was called away for an emergency procedure with the chief resident and had Dr B remain to complete the repair. When I returned, there was a signficant remaining amount to complete as the patient was not tolerating the procedure despite multiple epidural boluses and one dose of IV fentanyl as well as local infiltration of lidocaine.
Anesthesia was called as we were considering completing the repair in the OR. They decided to redose the epidural with precedex as well as give IV fentanyl. Pt was comfortable at this time. The deep tissue was brought together with 2-0 vicryl and then the sulcus laceration was repaired as well. There was a left labial laceration which was repaired with 3-0 vicryl. The right periurethral laceration was repaired with 4-0 vicryl in a running fashion. A bimanual was performed and the fundus was firm. Some oozing was noted from the periurethral lac and another interrupted was placed. Final inspection shows no further lacerations. A vaginal packing was placed as well as a foley catheter.
Pt tolerated the remainder of the procedure well
EBL 1200cc, CBC collected
Electronically signed by DO at 03/02/2024 5:12 PM EST
CNM - 03/02/2024 4:47 PM EST
Formatting of this note might be different from the original.
Postpartum patient following PPH of 1200mL and chronic anemia prior to delivery.
Currently tachycardic, HR ranging 110s-120s. Denies dizziness, burred vision, SOB.
Discussed updated hgb 7.7
Discussed at length possible need for blood transfusion due to tachycardia and EBL.
Patient desires blood transfusion now.
1unit PRBC ordered. Dr. DO consulted and aware of patient's status.
Electronically signed by CNM at 03/02/2024
