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Past delivery12/25/2023 ![]() ![]() If the delivery is uneventful, it gets codified as O80, Encounter for full-term uncomplicated delivery. Under general coding rules, this would establish the principal diagnosis, because it is the reason that occasioned the admission. A patient may come into the hospital full-term due to spontaneous rupture of membranes with spontaneous onset of labor. OB cases are unusual in that a PD may be present on admission indicator-no (POA-N). When I reviewed charts and found a solitary code for anemia, for example D50.9, Iron deficiency anemia, unspecified, I knew a code was missing (O99.02, Anemia complicating childbirth). Viral hepatitis, malnutrition, obesity, acute asthma attack (“diseases of the respiratory system”), acute appendicitis (“diseases of the digestive system”), cancer (“malignant neoplasm”) – everything is covered. 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” can be found in O94-O9A. There are O codes indicating that a condition in any other body system is impacting the pregnancy. You then would add the codes that told the remainder of the story: what was injured, the circumstances of the incident, the outcome of the delivery, how many weeks pregnant she was, how she delivered, whether there any other complications, etc. If she came in for an “unrelated” condition, there should be an O code – as a physician, I cannot recall a single patient who went on to deliver during an admission whose PD was not a complication of (or complicating) the pregnancy.Īs an example, a patient in the third trimester who was involved in a motor vehicle collision and brought in for observation who went on to deliver would warrant the “O9A.22, Injury, poisoning, and certain other consequences of external causes complicating childbirth” code. The primary diagnosis (PD) is always an “O” (for obstetrics) code. It is easy to identify an obstetrics inpatient who has delivered a child from the codes on her abstract. EDITOR’S NOTE: This is the second and final installment in a two-part series on OB coding. ![]()
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