Wiki What is the determination for high-risk?

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jademound

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A common disagreement between the coders in our facility is when to use to the high-risk codes for prenatal care. For example, a patient who is 40 years old and has delivered 7 children, prior to this pregnancy, comes in for an OB visit. The doctor does not specifically state that it is a high-risk pregnancy, but it is obvious that she "elderly" and has "grand multiparity". Would you use the V22.1 or V23.82 & V23.3?
 
what is determination for high-risk

If the physician documented her age, then use that code. If her age isn't specifically mentioned but the previous pregnancies are, then use the grand multiparity code. If he has not mentioned her age nor her previous pregnancies, then use the V22.1

Age and grand multiparity are high risk pregnancy codes and are valid given your information, however, if the physician did not put it in the record I would be hesitant to use either on my own. You might query the physician and he could amend the record to reflect her age and previous pregnancies and then the high risk code could be used.
 
I would not hesitate to make the connection the she is AMA due to her age and mutiparous due to her numerous pregnancies. The I9 and I10 codes clearly define the parameters for what constitutes high risk. I think V22.1 would be under-reporting since her record includes information about her parity and age. I would use code o09.52x/V23.82 "supervision of eldery mutligravida" without hesitation. I don't know if the V23.3 is necessary since V23.82 includes the patient is multiparious, but it certainly couldn't hurt since she's a GRANDmultip. I think you got it exactly right.
 
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