Wiki would this be acceptable dictation for NST 59025

[lsilbaugh]

prenatal visit
vitals complete

Provider Exam: Vaginal Exam: G1P0 37.3 wk Sent from clinic to rule out PROM She reports active fetal movement

Toco no contraction
FHR 150, moderate variabilities with acceleration no deceleration
Amni Sure negative
AFI 19 cm Results: reactive



59025-26
99211-25 for the exam?

 

[nielynco]

prenatal visit
vitals complete

Provider Exam: Vaginal Exam: G1P0 37.3 wk Sent from clinic to rule out PROM She reports active fetal movement

Toco no contraction
FHR 150, moderate variabilities with acceleration no deceleration
Amni Sure negative
AFI 19 cm Results: reactive



59025-26
99211-25 for the exam?

59025-26 only, but not the pelvic exam which would be included as part of the prenatal visit.

 

[lsilbaugh]

59025-26 only, but not the pelvic exam which would be included as part of the prenatal visit.

Hello! I am still struggling with dictation. In this scenario, the provider wrote in the chart

Reason for visit as stated by patient: nonstress test
Reason for Visit: Chronic Hypertension

Prenatal Information:
Gravida: 13
Current Pregnancy Complications: hypertension

EDD:
Expected Due Date: 00/00/0000
EGA (weeks): 31.6 Week(s)
Antenatal Steroids:

EGA (weeks): 31.6 Week(s)
If 24 to 34.6 weeks, were antenatal steroids initiated?: no...
Reason steroid not initiated: not at increased risk for preterm delivery
Vital Signs Measurements:
03-06-2024 11:21
Temp (degrees F) degrees F: 98.5
Temp (degrees C) degrees C: 36.9
Heart Rate Heart Rate (beats/min) : 77

Provider Exam:
Vaginal Exam: Blood pressure is 144/86, 139/86 biophysical profile pending
Results: reactive

The ultrasound results are posted later that day by the Diagnostician. Is it okay to still code for the bpp w/nst?

 

[nielynco]

Hello! I am still struggling with dictation. In this scenario, the provider wrote in the chart

Reason for visit as stated by patient: nonstress test
Reason for Visit: Chronic Hypertension

Prenatal Information:
Gravida: 13
Current Pregnancy Complications: hypertension

EDD:
Expected Due Date: 00/00/0000
EGA (weeks): 31.6 Week(s)
Antenatal Steroids:

EGA (weeks): 31.6 Week(s)
If 24 to 34.6 weeks, were antenatal steroids initiated?: no...
Reason steroid not initiated: not at increased risk for preterm delivery
Vital Signs Measurements:
03-06-2024 11:21
Temp (degrees F) degrees F: 98.5
Temp (degrees C) degrees C: 36.9
Heart Rate Heart Rate (beats/min) : 77

Provider Exam:
Vaginal Exam: Blood pressure is 144/86, 139/86 biophysical profile pending
Results: reactive

The ultrasound results are posted later that day by the Diagnostician. Is it okay to still code for the bpp w/nst?

Only one person gets to report the interpretation of the BPP w/NST. It sounds from this note that your provider got the results from another source and is simply reviewing the result. In that case, it is not a billable service, just part of the review of data which was part of the prenatal visit.