Coding, Classification & Reimbursement

  • 1.  Pregnancy Complications

    Posted 04-11-2018 15:20
    ​​Hi All,

    I will be the first to admit, OB coding is not my forte.  I have a question about Pregnancy Complications that may or may not be complicating the pregnancy on the current admission. If a patient has a bacterial vaginosis (venereal) during pregnancy, should that be coded if it is not present on the current admission or when the patient delivers? I am thinking not, but our OB Doctor lists everything a patient had during the current pregnancy and any previous pregnancies and it gets confusing. 

    Also, if the patient abused drugs and/or alcohol during the pregnancy, but the drug screen is negative during the current admission, would you code that as a pregnancy complication? I was going to code it as Drug Abuse in remission but my Encoder throws up an edit saying I need a pregnancy complication code. I am not sure what to do about the alcohol.  The OB doctor only said "History of."  He did not say "History of" during this pregnancy.

    Summary of OB Physician Notes:

    Poor Prenatal care. Poor compliance with OB Visits.

    Pt has been lost to follow up since 30.2 weeks on 2/2/18. Fundal height decreased at 34 cm. Discussed she is measuring small.

    She presented at the office today and was sent to Labor & Delivery for Repeat C/S.

    Gestational anemia.

    H/O methamphetamine abuse, admit Urine Drug Screen was negative.

    Methamphetamine Abuse, in rehab, 11/7/17, 17.6 weeks gestational age.

    AFP-Negative.

    T-dap given on 12/29/18.

    Wet prep on 8/14/17 at 5.5 weeks showed asymptomatic Bacterial Vaginosis and Trichomonas, no mobiluncus.

    Trichomonas and Bacterial Vaginosis on Wet Prep on 11/7/17. Patient and Significant Other treated. 

    Tobacco: Started smoking 1-2 cigarettes a day at age 16.

    H/O drinking beer and Vodka on the weekends.

    H/O Severe Preeclampsia with her first baby.

    Discharge Summary:

    R-C/S at 39.2 wks.

    Wt. 5 lb 7.2 oz, VTX, thick meconium, left paratubal cyst on a long stalk removed, Moderate omental anterior abd adhesions lysed.

    Adm labs: Hb- 10.6, PLT- 225.

    POD-1 labs: Hb- 8.7, PLT- 207.

    Gestational anemia.

    Poor PNC. Patient has been lost to follow up since 30.2 wks on 2/2/18.

    She presented at the office, fundal height was decreased at 34 cm, S<D, and was sent to L & D for R-C/S.

    AFP- Negative.

    T-dap given on 12/29/18.

    Trichomonas and BV on Wet Prep on 11/7/17.

    H/O methamphetamine abuse, adm UDS was negative.

    Tobacco.

    H/O drinking beer and Vodka on the weekends.

    H/O Severe Preeclampsia with her first baby.

    Thank you for any education you can give me on the subject!!



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    Kayla Hill, RHIA
    Director of Health Information/Privacy/CDI
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