# Hx Previous C/S - need help



## PatriciaM (Oct 19, 2010)

I have been trying to find a code for history of a previous c/s - pt is current pregnant, but the dr. wanted it coded - does it need to be captured?


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## gost (Oct 19, 2010)

Look under Delivery, Complicated, Previous, Cesarean delivery - 654.2x.

I know someone will argue that a previous C-Section is not necessarily a complication of the current pregnancy.  That is debatable but, whether it is or not, I believe the fact that the doctor is considering it in his or her current treatment justifies the code.

Hope that helps.


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## preserene (Oct 19, 2010)

No Gost, dont say that. No one who really understood the sequale of previous Cesar will  argue with you. It is one of the major conditions *complicating* pregnancy ; even be it first cesar done; causes may be recurrent or nonrecurrent but it is important for the doctor for evaluate which pt would go for trial of labor which would go for rupture,which would go for cesar again and so on.
Have n't we heard of "First Cesarean always Cesarean"  Phrase (though it may not be mostly). 

I feel this  previous LSCS( the more the numbers the more the high risk) or previous Classical CS (definitely) merits for Supervision of *high risk pregnancy*- *Vcode 23.4x* along with your code, though sometimes the career may not accept the previous one cesarean. But for Doctor she is a patient of high risk an dall the more if it is a recurrent cause


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## PatriciaM (Oct 20, 2010)

Thanks for your help!!!   So appreciate it!!!


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## MJ4ever (Nov 12, 2010)

The only time you are allowed to use a High risk pregnancy diagnosis, is, if the provider notes it in the documentation; otherwise, you would use 654.23 for current pregnancy with previous c-section.

Always make sure the diagnosis selected is supported in the documentation.

Barbara


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## preserene (Nov 12, 2010)

So for eg if the patient is previous 4 cesarean , and if not documented as  high Risk Pregnancy you would keep quiet even though you know it is a high Risk Pregancy?
 It is risky to leave a patient of high Risk pregnancy. One day she would rupture her uterus even at  24 weeks.
 We do have to critically think certain times and query the physician. After all "ERR IS HUMAN"; may be he was busy or forgot.  For the benefit of doubt, we should always query and for the benefit of better outcome for the patient.

I know when not documented ,it never happened .No1 rule in coding. But it did not say do not query and try to solve the issue.


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## sugihara (Nov 14, 2010)

A previous C-section is not a complication of pregnancy. The condition causing the previous c-section may be a complication of the current pregnancy, and might possibly warrant a second c-section, but the previous c-section itself is not grounds for categorizing the current pregnancy as high risk. As coders and billers, we do not make the decision of who is high risk and who is not. Only a healthcare professional can make this decision.

The risk is not during pregnancy, but potentially during labor and delivery. It is, of course, uterine rupture. Uterine rupture usually occurs during active labor, but rarely occurs during the third trimester of pregnancy. Of all women going into labor, the risk of uterine rupture is 0.017 - 0.07%.  Of women who have had a previous C-section, the risk is 0.07 - 1%. This is approximately the same risk of rupture for women who have been in a previous car accident, have had a previous first trimester abortion or have had other pelvic trauma, including a previous forceps delivery. We do not categorize these pregnancies as high risk or complicated.  The real risk is for women who have a scarred uterus and then are induced or have their labor augmented with pitocin or prostaglandins—a common occurrence in a hospital setting. Depending on the study, the risk of uterine rupture for this group of women rises 15-fold over women who are allowed to labor spontaneously.

The phrase, “Once a cesarean, always a cesarean” was coined in 1916 by Dr. Cragin.  It is an archaic phrase and no longer reflects modern maternity care in this country. ACOG recently updated their recommendations regarding VBACs:  VBAC is a safe and reasonable option for most women, including some women with multiple previous cesareans, twins, and unknown uterine scars. ACOG also states that respect for patient autonomy requires that even if an institution does not offer trial of labor after cesarean (TOLAC), a cesarean cannot be forced nor can care be denied if a woman declines a repeat cesarean during labor.


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## preserene (Nov 15, 2010)

sugihara said:


> A previous C-section is not a complication of pregnancy. The condition causing the previous c-section may be a complication of the current pregnancy, and might possibly warrant a second c-section, but the previous c-section itself is not grounds for categorizing the current pregnancy as high risk. As coders and billers, we do not make the decision of who is high risk and who is not. Only a healthcare professional can make this decision.
> 
> The risk is not during pregnancy, but potentially during labor and delivery. It is, of course, uterine rupture. Uterine rupture usually occurs during active labor, but rarely occurs during the third trimester of pregnancy. Of all women going into labor, the risk of uterine rupture is 0.017 - 0.07%.  Of women who have had a previous C-section, the risk is 0.07 - 1%. This is approximately the same risk of rupture for women who have been in a previous car accident, have had a previous first trimester abortion or have had other pelvic trauma, including a previous forceps delivery. We do not categorize these pregnancies as high risk or complicated.  The real risk is for women who have a scarred uterus and then are induced or have their labor augmented with pitocin or prostaglandins—a common occurrence in a hospital setting. Depending on the study, the risk of uterine rupture for this group of women rises 15-fold over women who are allowed to labor spontaneously.
> 
> The phrase, “Once a cesarean, always a cesarean” was coined in 1916 by Dr. Cragin.  It is an archaic phrase and no longer reflects modern maternity care in this country. ACOG recently updated their recommendations regarding VBACs:  VBAC is a safe and reasonable option for most women, including some women with multiple previous cesareans, twins, and unknown uterine scars. ACOG also states that respect for patient autonomy requires that even if an institution does not offer trial of labor after cesarean (TOLAC), a cesarean cannot be forced nor can care be denied if a woman declines a repeat cesarean during labor.


“This is approximately the same risk of rupture for women who have been in a previous car accident, have had a previous first trimester abortion or have had other pelvic trauma, including a previous forceps delivery. We do not categorize these pregnancies as high risk or complicated.”- A clip of your quote:

Where did you get this? Can an expert OBGYN accept this statement?
Please take a copy of your statement (Post) and  clarify with your OBGYN whether they would accept your posting of this. (of course some strands of facts are there coupled with unacceptable points too in yours). And also place the documents that directs you to say so, in the OBGYN literature or the CPT guidelines, please.
In my whole of ObGyn career I never knew this! I had been there for more than 50000( more than fifty thousand cesereans-from hysterotomy to planned LSCS) , we did not take it for granted like this. How many ruptures I have come across, how many previous cesars  were there that we take concerns and why do we give frequent subsequent follow up for such cases, how many of them do we admit in hospital at 3rd trimester, and how many of them, when failed to show up have ruptured on the onset of labor while at their home/ rural dwellings before coming to hospital;  But you say they rupture at hospital only on induction. In Hospitals, they do not allow them to rupture with all their observation and expectant line of managements (ofcourse rarely it does so beyond their reach. I am not coming to an argument that even rupture can occur with any induction at the time of labor, even with forceps delivery or VE, even with some mal presentation Short statured, CPDs…Oh, it is huge topic; Rupture occurs with deep transverse arrest too. I am not coming to that.) Nor do I say that you make the patient unnecessarily making it aware of.
How many of them are left for VBACS and how many previous cesars can be allowed to do so, do you think we are not aware of. I have succeeded in many in doing so. That is not the point.

*My point here for coding: that is this:   Previous cesareans are conditions complicating Pregnancy and they are under the high risk group and  merit for supervision High risk of pregnancy  and not for  normal /incidental to pregnancy..*
Not  even  a debate about the how  many previous cesars are to be considered as high risk. Your point of discussion goes that “the previous cesars we do not take it as high Risk”.
The Phrase “THAT FIRST CESAR IS ALWAYS CESAR” is there in the OBGYN Specialist  books  also , for the fact, not that they claim it to go for Cesar again and again, but  for the people who read  it to understand while dealing with such cases  not to  ignore,( just as the way you ignore now and  saying it was an old dictum and occurrence, and not to weigh it any more).  *Such medical dictums and the phrases are for endless time because the human anatomy is also the same for endless time, though the cutting edge medicines and technology are making the burden  less.*
Then your statement that there is not a SCAR in the UTERUS, after Cesar (saying that it is like all other “normal untried uterus”, oh, the whole concept of previous cesareans  is  up in the air.
You do not see the scar obviously  and literally  there, even it is previous 6-8 cesarean while opening up, but  the  place and the tissues (musculature) there at that site they do recognize the site of scar to deal with.  The history says there had been 17 previous cesareans  for the merits of it!! But it does not mean that you would ignore the previous cesareans.  Whatever the number of CESAREANS, THE  INHERENT SCAR  made by a cesarean IS THERE ALWAYS. 
Have you heard of  the TERMS “SCAR DEHESCENCE, SCAR ENDOMETRIOSIS” ?; all these refers to the scar of previous cesarean or surgery on the uterus.
Previouss cesareans and the previous Myomectomy scars are to be  considered for the future pregnancy  to deal with.  
 I HAVE been with decades OF EXPERIENCE IN THIS LINE. But I never said that the old dictums  should be ignored in the way you stipulate. I HAVE COME ACROSS MANY RUPTURES  OF PREVIOUS CESARS (the risks rate increase with more numbers of cesars)  with out PG, syntocinon, or into the active labor. I have an experience with upto  previous 7 cesareans.
Rupture has occurred with from previous 2 cesareans even at the onset of labor. More so with previous myomectomy scars.  Rarity is not an excuse to waive it out.
My point is when a patient is at home or in her village/ town , when gets into pain has the chances of rupturing before she reaches hospital if she delays- be it preterm or term. Why we go that far. We label them and educate them and make them understand the importance of the of the previous surgeries  there.
 Previous Classical Cesarean or Hysterotomy can also have chances of giving way even at late 2nd trimester. You are telling “it is rare in 3rd trimester”!!. Rare or not, chances are there from your own statement. So please do not make the previous Cesarean in par with the NORMAL PREGNANCY
So as per your statement , till induction  point, we will not label them as Higk risk?  Even the very normal is with out high risk label till that point.
Well, at the end of the statement , what I understand  is that you point out   that it  is not our concern to say whether it is high risk or not.  It is the  Physician’s task and statement/document. 
YES CODERS ARE THERE ONLY TO CODE WHAT THE PHYSICIAN DOCUMENTS . I GOT THE POINT!!!
I am not coming for the debate anymore!!   Bye


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## preserene (Nov 15, 2010)

Hi I apologize for the size of a few lines there. I did not mean to have big that way.  My computer does not work to reduce that size again. Sorry for that!


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## preserene (Nov 15, 2010)

"Of women who have had a previous C-section, the risk is 0.07 - 1%. This is approximately the same risk of rupture for women who have been in a previous car accident, have had a previous first trimester abortion or have had other pelvic trauma, including a previous forceps delivery. We do not categorize these pregnancies as high risk or complicated."-Your quote.
 That rupture rate of 07-1% , meaning one in 100 previous cesarean women going for rupture uterus, is too high to treat them in par with the normal pregnancy, ,don't you think   so?
That *means*, *1in 100 previous cesarean women go for risk of morbidity* and how many of these "ruptured" would go for mortality, and as such, maternal Mortality Rate will go very high.

I know  that I would be rather concerned even 1 in 100,000 women goes for maternal Mortality due to obstetric cause or preventable cause. 

I got a clip of the news about the MMR in the US; Rising maternal mortality rate causes alarm, calls for action. The U.S. rate nearly doubled in a decade and is higher than in 40 other industrialized countries. Experts cite numerous possible reasons and steps that could be taken- May 22, 2010|By Shari Roan and Lisa Girion, Los Angeles Times. 

As stated by the 2005 World Health Organization report "Make Every Mother and Child Count".; that means every life is important.
 Women should not die in the richest country on earth from preventable complications and emergencies," Cox said in a news release.

Up to 40 percent of near misses are considered preventable with better quality of care, according to a 2007 study in the American Journal of Obstetrics & Gynecology.


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