SAB vs hemorrhage vs normal pregnancy

tag60

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I'm at a loss how to code this one. OB pt in for followup visit after seen at ER. Note as follows:

Pt with positive pregnancy test and vaginal bleeding x1 week. Seen in ER 6 days ago where ultrasound showed empty uterus and normal adnexa. Admits her bleeding has stopped but was heavy for the past week.

Sono done: anteverted uterus, EMS 1.0 cm, thin and homogenous. CL 2.9 cm. Ovaries normal.

A/P: S/p likely completed SAB. Ultrasound and beta HCG downtrending with resolution of symptoms consistent with completed AB.

Provider then chooses Z34.80 (supervision of normal pregnancy) for dx code.

I considered antepartum hemorrhage code (O46.90), but bleeding has stopped...yet it was the reason for ER visit and this followup.
versus
SAB (O03.9)...but apparently provider isn't willing to state that definitively
versus
what provider chose (Z34.80).

How would you code this? (I can query provider, but I really need to make sure I'm doing so for a good reason.)

Thanks in advance!
 

tracylc10

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I have been thinking more about this and since the md has not stated definitively what the dx is, you really should query the provider to see what they would like it coded as. I would definitely not code it as an encounter for normal pregnancy. Clearly from the u/s the pt has miscarried, O03.9.
 
Last edited:

Cmama12

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I think I would use the antepartum hemorrhage or threatened abortion code since the report does not state the miscarriage dx definitively due to "likely" and "consistent with".
 
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