Uncertain gestational age ultrasounds

SANEAST

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Hi there!

Patient comes in for 4-5 week check, OB chart not started, patient has upt which is positive but uncertain gest age as she was nursing and through u/s you cannot see anything so they dont know how along the patient really is.

Second visit 1-2 weeks later, OB record starts and physician does another u/s to confirm if the pregnancy is normal or not (Threatend AB, Ectopic etc..) since she was nursing and doesnt have a LMP.

My question is....how do I code this second visit? I know its based off of symptom or what you know at the end of the visit. So if the end of the visit is still not know if its normal or not do we still code uncertain gest age? The Drs say they do this to rule out threatened AB but we cannot code rule out.


Thanks everyone!
 

SANEAST

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Even though I used positive pregnancy test with the first visit? I thought you cannot use this code if the obstetrical record is started and since I already billed this? Correct me if i'm wrong :)
 

SANEAST

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Yes Fetus was seen and everything looked normal. Dr. wanted to use threatend AB since thats the reason the patient was getting the ultrasound, but I do not agree with that since it was not the outcome.
 

SANEAST

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Is V28.81 usually used in second trimester? (fetal anatomic survery) She would still be first trimester.

Would V28.3 be appropriate?
 

jmcpolin

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Hmm I have never heard that before, at my old radiology practice we used to use v28.89 for all normal ultrasounds no matter what trimester the patient was in.
 
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