Anesthesia Coding Alert

Question: A patient delivered via cesarean section following a previous c-section. Our provider administered anesthesia but did not mention the patient's antepartum or postpartum condition in her documentation. What diagnosis should we report?

New Hampshire Subscriber

Answer: Report 654.21 (Previous cesarean delivery; delivered, with or without mention of antepartum condition). You might be tempted to report 654.20 (... unspecified as to episode of care of not applicable). Diagnosis 654.21 is the better choice, however, because you state that the patient delivered. You would submit 654.20 if your provider's documentation did not mention any outcome.