Inpatient Facility Coding & Compliance Alert

Question: A 36-year-old pregnant female, primigravida, was admitted at 42 weeks of gestation. A low cervical C-section was performed due to breech presentation. The patient required IV antibiotics during labor and delivery for a generalized infection of Group B Streptococcus. The patient desired sterilization, so a bilateral tubal ligation was performed after delivery. How should we code the diagnoses and procedures associated with this admission?

Washington Subscriber

Answer: The principal diagnosis will be intrauterine pregnancy, breech presentation (652.21, Breech presentation without version delivered; delivered, with or without mention of antepartum condition) with a secondary diagnosis of post-term pregnancy (645.11, Post term pregnancy delivered with or without antepartum condition; delivered, with or without mention of antepartum condition). Other diagnoses you should include are 041.02 (Streptococcus infection in conditions classified elsewhere and of unspecified site streptococcus group b) and V25.2 (Encounter for contraceptive management; sterilization).

The principal procedure will be 74.1 (Low cervical cesarean section) for the cesarean section and 66.39 (Other bilateral destruction or occlusion of fallopian tubes) for the bilateral tubal ligation.

Caveat: It is not clear whether your mention of the "generalized infection of Group B Streptococus" means the patient was positive for Group B Strep or whether you mean she experienced septicemia/sepsis during labor. The codes listed above refer to positive Group B Streptococcus in pregnancy. If the patient experienced septicemia or sepsis instead, report 659.31 (Generalized infection during labor delivered; delivered, with or without mention of antepartum condition) instead, with the appropriate additional code for sepsis.