Question: I am looking for the correct diagnosis for a pregnant patient who has a history of preterm labor. Normally, I would use V23.49, but a coworker wants to use 644.20. Which is correct?
Montana Subscriber
Answer: You can report 644.20 (Early onset of delivery; unspecified as to episode of care or not applicable) only if the patient now has early onset of delivery.
For a history of this, you will use V23.41 (Pregnancy with history of preterm labor) because she is now pregnant and you do not yet know if this will be a complication for this pregnancy.
Keep in mind: If she is not pregnant, you would use V13.21 (Personal history of preterm labor).
Watch out: You shouldn't use V23.49 (Pregnancy with other poor obstetric history) because V23.41 is more specific for this history. Code V23.49 represents any condition other than preterm labor.