trinalankford
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I'm hoping someone might be able to shed some light. I've spent quite a bit of time researching this, and it is so early in the ICD-10 process, I really am not finding anything.
I've been instructed by a lead coder to NOT code the weeks of gestation if it is stated as "estimated," "approximately," etc., because it is not "exact."
In thinking this over, I'm not sure I agree with this. By virtue of the term ?estimated gestational age,? this is as exact as we will ever get. An MD cannot say with absolute certainty how many weeks? pregnant any patient is. It will always be ?estimated,? based on dates, anatomy measurements, whatever the case may be. The provider will give you an estimation of the weeks of gestation at the time of that patient?s presentation, having taken into consideration all data he has. Therefore, because we will never get anything BUT an ?estimated? gestational age, shouldn?t we use the gestation weeks, even when it is indicated as ?estimated? or ?approximately??
This comes up a lot on OB ultrasounds, for example, but I'm also running into it in the ER. With ICD-10, any pregnancy complication requires TRIMESTER plus the extra code for the weeks of gestation, so if I am defaulting to unspecified simply because the EGA was given as "estimated," this patient now has TWO unspecified codes on her chart, one for pregnancy complication unspecified trimester and unspecified weeks of gestation.
I'm wondering how other institutions are interpreting the weeks of gestation guideline and the word "estimated"....which appears on EVERY obstetric chart out there. I'm inclined to code the EGA, simply because that is how many weeks the provider BELIEVES the patient to be, which is as close as we can ever humanly know.
Is this taking the context of the guideline too literal?
If anyone knows of any written literature out there supporting this issue, one way or the other, I'd appreciate receiving a link. Thank you!
I've been instructed by a lead coder to NOT code the weeks of gestation if it is stated as "estimated," "approximately," etc., because it is not "exact."
In thinking this over, I'm not sure I agree with this. By virtue of the term ?estimated gestational age,? this is as exact as we will ever get. An MD cannot say with absolute certainty how many weeks? pregnant any patient is. It will always be ?estimated,? based on dates, anatomy measurements, whatever the case may be. The provider will give you an estimation of the weeks of gestation at the time of that patient?s presentation, having taken into consideration all data he has. Therefore, because we will never get anything BUT an ?estimated? gestational age, shouldn?t we use the gestation weeks, even when it is indicated as ?estimated? or ?approximately??
This comes up a lot on OB ultrasounds, for example, but I'm also running into it in the ER. With ICD-10, any pregnancy complication requires TRIMESTER plus the extra code for the weeks of gestation, so if I am defaulting to unspecified simply because the EGA was given as "estimated," this patient now has TWO unspecified codes on her chart, one for pregnancy complication unspecified trimester and unspecified weeks of gestation.
I'm wondering how other institutions are interpreting the weeks of gestation guideline and the word "estimated"....which appears on EVERY obstetric chart out there. I'm inclined to code the EGA, simply because that is how many weeks the provider BELIEVES the patient to be, which is as close as we can ever humanly know.
Is this taking the context of the guideline too literal?
If anyone knows of any written literature out there supporting this issue, one way or the other, I'd appreciate receiving a link. Thank you!