tox screen positive in pregnancy

tag60

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Can I use the code for Drug use complicating pregnancy (O99.,32x), or is that me making a diagnosis when the provider has not...or does the documentation clearly support it and thus I may use it? (I'm confused!) Please see below. No other mention about this in the note except as below.

Assessment:
IUP at 36w2d
Poor adherence to prenatal care
Tox-9 screen positive for cannabinoids

Plan:
GBS today
OB check in 1 week

Thanks once again!
 
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The ICD-10 guidelines say "16. Documentation of Complications of Care; Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented."

Since the provider does not specifically say it's complicating the pregnancy, according to the above guidelines, you shouldn't report it as such. Another thing to consider is that a tox screen can show a false-positive (not saying that's the case here). For example, the allergy medication I take always causes a false-positive for PCP for me. Anyway, as they mention in the guidelines, I'd query the provider about it. Likewise for the poor adherence to prenatal care.
 
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