Wednesday, December 21, 2016

OB/Pregnancy-Childbirth-Puerperium Charts

Pregnancy Sample charts/Cases

1.       36 year old G2 P1 woman at 26 weeks pregnant and is being seen for gestational hypertension. At this time, she is not having any other problems. What is the correct diagnosis code(s)?

O13.2 Gestational Diabetes
O09.522 Elderly Multigravida
Z3A.2626 Weeks Pregnant

2.       A G1P0 patient was admitted in active labor at 38 completed weeks of gestation. She is a type 2 diabetic, monitored through this pregnancy with no complications and no use of insulin. A second degree perineal laceration occurred during delivery and was repaired. A female infant was delivered with Apgar scores of 9 and 9.

O70.1 Perineal Laceration
O24.12 DM Type 2
E11.9DM w/ No Complications
Z3A.3838 Weeks Gestational Age
Z37.0 Single Liveborn

3.       A 25 year old patient was admitted with difficulty breathing. She has AIDS and is 21 weeks pregnant. Workup reveals Pnueumocystis Carinii Pneumonia (PCP).

O98.712 Pregnancy complicated by HIV Disease
B59 PCP (pneumonia)
Z3A.2121 Weeks Gestational Age

4.       A G3P2 patient was admitted at approximately 34 weeks gestation with a history of contractions for the last 24 hours. She was having contractions every 5 to 8 minutes. An ultrasound showed an intrauterine fetal death of triplet 2, but the other two were progressing normally. The contractions stopped for about 24 hours and then restarted. It was noted by the physician that the continued contractions were due to fetus 2. The patient was given magnesium sulfate for tocolysis which was unsuccessful. The patient developed a fever with an infection of the amniotic sac. The patient continued to be in active labor and due to the infection was allowed to spontaneously deliver the three infants, two liveborn and one fetal death. The patient experienced no postpartum complications. Assign the diagnoses codes.

O60.14X2 Preterm Labor
O36.4XX2 Intrauterine Fetal Death
O30.103 Triplet Gestation
O41.1030 Infection of Amniotic Sac
Z3A.3434 Weeks Gestation
Z37.61 Outcome of Delivery


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  2. Great coding examples, however, there is an error on the first question. O13.2 is not Gestational Diabetes. Correct code but incorrect description.

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