I code for newborn/delivery.
Assessment & Plan
38.1 week old AGA female newborn born via vaginal delivery complicated by maternal positive GBS, adequately treated.
Plan:
See standing orders
Routine anticipatory guidance
Routine newborn care
Maternal GBS positive, adequate IAP. EOS risk screen 0.03 for well appearing infant. No cultures or antibiotics indicated. Routine vitals. Observe for 24-48 hours for signs of infection/sepsis.
Feeding:
Mother plans to breast feed exclusively. She was educated on the benefits of breastfeeding.
Hyperbilirubinemia risk: Bilitool
Dx codes billed are Z38.00 - Single liveborn infant, delivered vaginally
P00.82 - Newborn affected by (positive) maternal group b Streptococcus (GBS) colonization
My question is, if the GBS was adequately treated, can Z20.818 - Contact with and (suspected) exposure to other bacterial communicable diseases be used instead of P00.82? Or would P00.82 be used because documentation states "observe for 24-48 hours for signs of infection/sepsis"?
Any insight is greatly appreciated
Assessment & Plan
38.1 week old AGA female newborn born via vaginal delivery complicated by maternal positive GBS, adequately treated.
Plan:
See standing orders
Routine anticipatory guidance
Routine newborn care
Maternal GBS positive, adequate IAP. EOS risk screen 0.03 for well appearing infant. No cultures or antibiotics indicated. Routine vitals. Observe for 24-48 hours for signs of infection/sepsis.
Feeding:
Mother plans to breast feed exclusively. She was educated on the benefits of breastfeeding.
Hyperbilirubinemia risk: Bilitool
Dx codes billed are Z38.00 - Single liveborn infant, delivered vaginally
P00.82 - Newborn affected by (positive) maternal group b Streptococcus (GBS) colonization
My question is, if the GBS was adequately treated, can Z20.818 - Contact with and (suspected) exposure to other bacterial communicable diseases be used instead of P00.82? Or would P00.82 be used because documentation states "observe for 24-48 hours for signs of infection/sepsis"?
Any insight is greatly appreciated