Anesthesia Coding Alert
Submit Multiple Diagnoses for C-section, Failed VBAC
Question: A patient had a C-section following a failed VBAC due to fetal distress. She had vaginal bleeding; the OB-GYN performed a hysterectomy during the C-section. What are the best diagnoses for this encounter? Connecticut Subscriber Answer: You have multiple diagnosis options, depending on the supporting documentation. Some possibilities for delivery include: O80 (Encounter for full-term uncomplicated delivery), O34.211 (Maternal care for low transverse scar from previous cesarean delivery), and O77.9 (Labor and delivery complicated by fetal stress, unspecified). The correct diagnosis for an unsuccessful VBAC depends on the reason why it was unsuccessful. Presuming an epidural catheter was placed for the VBAC, the delivery itself can be reported with 01967 (Neuraxial labor analgesia/anesthesia for planned vaginal delivery [this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor]) and +01969 (Anesthesia for cesarean hysterectomy following neuraxial labor analgesia/anesthesia [List separately in addition to code for primary procedure performed]).
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