pregnancy coding scenarios

Physical exam significant for occipital-parietal flattening on the right side (plagiocephaly) and mild torticollis. Well nourished, well-groomed, A&Ox3, mood and affect calm. 51728 with bladder voiding pressure studies, any technique Physical exam significant for occipital-parietal flattening on the right side (plagiocephaly) and mild torticollis. Cardiac: S1/S2, no S3/S4, no murmurs. Vital Signs: BP 128/64, T 98.7°F, Ht. Moderate activity 3-5 days per week. No specific impact noted. Supraventricular Tachycardia. G3P3003. 51726 Complex cystometrogram, calibrated electronic equipment Good luck! Pregnant state, incidental. Any use of hysteroscope can be billed as a hysteroscopic procedure. In ICD-10-CM abdominal tenderness is differentiated to address the rebound characteristic with different codes. Historically cycles have been regular lasting 28 – 30 days each. 1 V-Tach. Lysis of adhesions may be billed separately—either by reporting a separate CPT® code (see below) or by adding modifier 22 Increased procedural services to the primary procedure code—depending on the adhesions’ extent and based on the procedure’s documentation. The HELLP syndrome is characterized as severe preeclampsia with hemolysis, elevated liver enzymes, and low platelet count. O99.89 Pregnancy, complicated by disorder of specified body system Coding options also are sensitive to timing of these conditions, reflecting that preeclampsia, eclampsia, and HELLP usually occur during the second or third, The American College of Obstetricians and Gynecologists (ACOG) published a practice guideline for pregnancy induced hypertension in 2013 which includes a revision of the criteria for preeclampsia. Encounters for patients who are pregnant, in delivery, or in the puerperium, use codes from Chapter 15: Pregnancy, Childbirth and the Puerperium (O00-O9A). Encounters for patients who are pregnant, in delivery, or in the puerperium, use codes from Chapter 15 Pregnancy, Childbirth and the Puerperium (O00-O9A). Should I use E11.69 or E11.29? 2 Bradycardia. As there is a positive family history for breast cancer denoted with the three sisters identified as BRCA positive, the documentation supports the patient’s susceptibility to a malignancy of the breast. 51727 with urethral pressure studies, any technique V76.2 Routine screening pap test, intact cervix Identifying the specific area of abdominal pain is important, as some payers may deny claims with “unspecified” codes. Mass is tender, easily moveable, firm to touch. Subtracting the voiding abdominal pressure from the total bladder pressure on voiding gives the most accurate determination of true voiding pressure, also known as detrusor pressure. 2016 2017 2018 2019 2020 2021 Billable/Specific Code Maternity Dx (12-55 years). The global surgical package as defined in CPT® includes: Global days associated with procedures are zero, 10 days, or 90 days. Like a patient has … ICD-10-CM can now capture the side of the body. [This code is resequenced as well as revised.] It must tell a story giving a clear picture describing the difficulty encountered in the procedure. No family history of ovarian or cervical cancer. Positive family history for breast cancer – mother and all three sisters. V04.89 Need for prophylactic vaccination and inoculation against other viral diseases, Index to Diseases for ICD-9-CM under the word itching states “see also Pruritis”. Scenario #5 - CODES Diagnoses (Primary) V25.41 - Surveillance of previously prescribed contraceptive pill 595.9 Cystitis, unspecified V72.31 Routine GYN examination V74.5 Special screening examination for venereal disease V76.2 Screening for malignant neoplasms of cervix (PAP) V72.41 Pregnancy exam or test, negative result Begin Megacode 3 . As with all coding, remember to imagine how the stor While rushing for the newest iPhone, John fell down the stairs. 3. Most role plays will last only a minute or two. She has been an educator of coding and HIM for more than 15 years. ICD-10-CM provides four alternative choices that map to the ICD-9 code 616.10 Vaginitis and vulvovagi nitis, unspecified. In this scenario, we applied the ACOG guideline and are not coding the patient’s symptoms as they are considered. Swab specimen obtained for microscopy exam. Earn CEUs and the respect of your peers. Bookmark the Centers for Medicare & Medicaid Services’ (CMS) website in your “favorites” menu, and be aware of local coverage determinations (LCDs) for your Medicare payer. Previously, she was a corporate coding manager for a large healthcare system and has more than 30 years experience as a HIM Director and coding consultant. As per ICD 10 coding, incidental pregnancy is a test that proves that the patient is pregnant. R10.31 Pain localized to other parts of lower abdomen, right lower quadrant pain In support of this objective, we have provided outpatient focused scenarios to illustrate specific ICD-10 documentation and coding nuances related to your specialty.The following scenarios were natively coded in ICD-10-CM and ICD-9-CM. Pelvic shows cervical motion tenderness and adnexal tenderness on the right. Pelvic exam is normal. Do you wish you knew some helpful tidbits to ease daunting coding tasks? No cyanosis. The procedure must be performed by, or under the direct supervision of, a physician, with all supplies provided by the physician. The rationale for abnormal findings in this encounter is based on the presence of the breast lump. The key word to find this status code in the Index to Diseases from Volume 3 is “Dependence” and then sub indent to the word “on” and then to the words renal dialysis Z99.2. No rebound tenderness or guarding of abdomen. LMP: occurred 2 weeks ago, normal cycle for her. Each scenario is selectively coded to highlight specific topics; therefore, only a subset of the relevant codes are presented. Social history: Physically active. Many companies produce a variety of equipment to accomplish ablations. 21 year old female G2P1001 with RLQ abdominal pain1 for the last 6 months. For example, the following codes are provided for category O25, Malnutrition in pregnancy, childbirth and the puerperium: O25.1, Malnutrition in pregnancy; O25.10, Malnutrition in pregnancy, unspecified trimester; O25.11, Malnutrition in pregnancy, first trimester; O25.12, … ACLS Megacode Scenario Simulations Put your ACLS skills to the test with these timed megacode scenarios. Coding Scenario #1 A fffifteen year old flfemale with her first pregnancy developed placenta previa in her 35th week. As the clinical status for this patient is not known, it does not have right versus left, e.g. Yes, combination codes, at times, will report the same information in one code rather than two codes required in ICD-9-CM. Coding and billing professionals must keep track of reporting requirements for visit services administered remotely using telemedicine and updates to the ICD-10-CM guidelines for reporting COVID-19 in pregnancy. are of childbearing age and have had an examination indicating the presence of cervical or vaginal cancer or other abnormalities during any of the preceding three years; or Abdominal pain that will not go away and irregular menses. Bowel sounds normal in all 4 quadrants. Vital Signs: BP 150/90, T 99.6°F, P 100, R 30. Family history positive for hypertension, migraines. As per American Congress of Obstetricians and Gynecologists’ guidelines, a well women exam includes both a pelvic exam as well as a clinical breast examination. 76802-each additional gestation (List separately in addition to code for primary procedure) 76805– Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation Ann Zeisset, RHIT, CCS, CCS-P, is an independent consultant on ICD-10-CM/PCS. ICD-9-CM Diagnosis Codes Patient admits to a history of alcohol dependence2. This low risk pregnancy may be billed with a package code if four or more visits were completed before the termination. ICD-9-CM includes a variety of vaccination codes while ICD-10-CM offers only one generic immunization code. From those graphs or images, a provider interprets the patient’s condition and makes recommendations about treatment, therapy, or surgery that is translated into a written report. Axilla normal, without palpable nodes. Long time history migraine headaches. Other Impacts Pap smear performed. As a contributor you will produce quality content for the business of healthcare, taking the Knowledge Center forward with your knowhow and expertise. The documentation and context of the pain presentation will determine if additional. Depending on the demographics of the region a hospital serves, its coders could determine code assignment for hundreds of deliveries and pregnancy-related services annually. solitary cyst of left breast. ICD-10 provides distinct coding options for the life-threatening HELLP syndrome to be coded as both a variant or complication of preeclampsia or eclampsia. R10.813 Right lower quadrant abdominal tenderness Cystometrogram measures how well the bladder stores and empties urine; for instance, for patients with symptoms of urinary incompetence. Bradycardia. Admission orders: called and faxed to L&D unit nurse. As patient history and circumstances will vary, these brief scenarios are illustrative in nature and should not be strictly interpreted or used as documentation and coding guidelines. The four options are N76.0 Acute vaginitis; N76.1 Subacute and chronic vaginitis; N76.2 Acute vulvitis; and N76.3 Subacute and chronic vulvitis. The vertex was presenting at 0 station. ICD-10 differentiates from ICD-9 in clinical terminology to describe preeclampsia as mild to moderate, severe, or unspecified. However, no provider would consider abdominal pain in pregnancy unrelated. N92.5 Other irregular menstruation Having her typical migraine now. ICD-10 increases the alternatives for hypertensive disorders in pregnancy (with or without the presence of proteinuria and/or edema); refer to an official ICD-10 guide for example alternatives. Headache, nausea and vomiting x 2 over last 48 hours. Some instruments incorporate heat, while others use cold. She had a postpartum pulmonary embolism Scheduled fine needle aspiration of left breast mass at the end of this week – with Dr. Smith. Coding options also are sensitive to timing of these conditions, reflecting that preeclampsia, eclampsia, and HELLP usually occur during the second or … Incidental pregnancy is a case when the patient has come for some other concern but has been diagnosed pregnant. Scenario #2A - CODES Diagnoses (Primary) V25.11 Insertion of intrauterine contraceptive device V72.41 Pregnancy exam or test, negative result Procedure Codes 58300 Insertion of IUD 81025 UPT Device: J7300 Intrauterine copper contraceptive or J7302 Levonorgestrel-releasing … Patient counseled on pain relief exercises. Urodynamic testing generally is performed by specially-designed equipment (calibrated electronic equipment), which contains graphs and/or images. Five siblings, four living. CMS does not follow CPT® guidelines, however. Referred for concern of delayed gross motor skills. Allergies: sulfa drugs, penicillin (anaphylaxis noted). If the rest of Chapter 15 doesn’t have a specific code, numerous “obstetric conditions not elsewhere classified which are complicating pregnancy, childbirth, and the puerperium… CPT® 2010 offered several revisions to urodynamic testing codes, as well as new and “resequenced” codes. The use of the best code may vary by payor according to what services were rendered and the insurance plan’s reimbursement of a well women annual visit versus reimbursement of pelvic and/or clinical breast examinations. “I’ve found a lump on my left breast and I need my annual GYN exam.”. CM/PCS Academies. V72.31 Routine gynecologic exam, with or without pap test Under Pruritis, vulvar that codes to 698.1, ICD-9-CM has a variety of vaccination codes, N76.Ø Acute vaginitis If the doctor’s documentation had just documented, “positive pregnancy test,” the code would be Z32.01, Encounter for pregnancy test, result positive. LMP December 20, 2013. Intrauterine pregnancy, twins, 33 weeks with premature rupture of membranes, and onset of labor three hours later. These “real world” examples can help you tackle day-to-day coding challenges in your OB/GYN practice. ICD-10 provides distinct coding options for the life-threatening HELLP syndrome to be coded as both a variant or complication of preeclampsia or eclampsia. conditions that could affect a future pregnancy, and that may be amenable to intervention. How much time was spent removing the adhesions before seeing the surgical field? Z15.01 Genetic susceptibility to malignant neoplasm of breast, 642.43 Mild or unspecified preeclampsia, antepartum condition or complication When coding separately for adhesions using a dedicated CPT® code, select an appropriate code based on location: For example, significant dense adhesions were dissected from the omentum to the anterior abdominal wall and left pelvic sidewall. – 88155 in addition to the screening code for physician interpretation of a cervical or vaginal specimen that has been screened by any method using any system of reporting • add-on code reported in addition to code for the technical service provided. There are different diagnosis codes for each. By Ann Barta, MSA, RHIA. Pelvic: External exam-vulvar redness, no vulvar edema and no adherent white clumps present; Speculum exam – vaginal walls pink, cervix intact, closed os, thin gray and foul smelling discharge noted in vaginal canal. – 88155 in addition to the screening code for physician interpretation of a cervical or vaginal specimen that has been screened by any method using any system of reporting • add-on code reported in addition to code for the technical service provided. Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings Sisters are BRCA. Next, let’s look at some COVID-related scenarios and associated code assignment: Pregnant mother with confirmed COVID-19; Code O98.51_, Other viral diseases complicating pregnancy should be sequenced first followed by code U07.1, COVID-19. 629.89 OR Other specified disorders of female genital organs Is the patient’s diabetes the cause of the UTI? 32 year nulliparous female well known to me presents today at 36 2/72 weeks gestational age for a scheduled prenatal visit. Are you new to obstetrics and gynecology (OB/GYN) coding? Pain is a dull ache. The following are scenarios most-commonly asked about by attendees during question-and-answer sessions while teaching OB/GYN. On iron supplementation. Current guidelines indicate that ICD-9-CM code 648.21 is the principal diagnosis for a woman with a pregnancy complicated by anemia who undergoes a cesarean delivery due to fetal distress not present at admission, says Susan Proctor, RHIT, CCS, CPC, a coding consultant in Willits, Calif., and an AHIMA-certified ICD-10-CM/PCS trainer. Refrain from intercourse for one week after starting. When coding, consider all documented factors such as current and pre-existing conditions, trimester, and age.

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