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E&M preterm preg at Hospital

  1. #1
    Default E&M preterm preg at Hospital
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    This is the full note-scrubbed. It is very lacking in documentation, suggestions on E&M would be appreciated.

    gravida III, para II, came in by ambulance due to preterm labor at 34 weeks. Suppose to go to (better equiped) hospital for delivery due to baby congenital heart problems, diverted here. 4 cm dilated, 80% effaced with presenting part high, fetal heart reactive. no regular contractions. Patient stabilized with mag sulfate of terbutaline and stadol. Patient to be transferecd for delivery to larger hospital, patient advised of possible delivery in transport.

    Diag: preterm at 34 wks, baby with congenital heart
    Plan: transfer within 15 minutes

  2. #2
    Is this your patient? I think if it is I would just include it under the global care, unless they have gone over the included number of visits.

    If that is the case or this is not your patient, what setting did you see this patient in? Was it the ED? If so I would suggest a 99281.

    Just my take on it,

    Laura, CPC, CPMA, CEMC

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