Ob-Gyn Coding Alert

Question: I’m looking for some guidance on coding of GBS bacteriuria in a pregnant patient. Here’s the note:

Visit Notes: Patient denies leakage of fluids (LOF), viable birth (VB). Reports good fetal movement (GFM) and having contractions (CTX) but nothing worth timing. Also, having lots more swelling in her feet, ankles, and legs she is very concerned with the swelling and high blood pressures. GBS needs done today. Overall feeling ok. Labs were completed and within normal limits (WNL) for gestational hypertension (GHTN). Plan for induction of labor (IOL) - scheduled for 37 weeks.

Assessment and Plan: (1) Z3A.36 - 36 weeks gestation of pregnancy (2) O13.3 - Gestational [pregnancy-induced] hypertension without significant proteinuria, third trimester

(3) R82.71 - Bacteriuria

However, I don’t think R82.71 is the correct code for this. I was thinking Z22.330 (Carrier of Group B Streptococcus), or maybe O99.820 (Streptococcus B carrier state complicating pregnancy). I did query the provider, and they suggested B95.1 (Streptococcus, group B, as the cause of diseases classified elsewhere). Any help would be greatly appreciated!

Pennsylvania Subscriber

Answer: The provider is ordering a GBS screening, but there is no evidence in this note that the patient has tested positive for GBS. You would only use a code for carrier state if she has confirmed GBS but has no symptoms but could pass it on to someone else. In the case of it being in the urine, it is a danger to the mother most often, not the fetus (which would not be the case if the GBS was present in the vagina or rectum and could be pass on to the baby at birth).

The B code can only be used as a secondary code to the primary (which could be R82.71 [Bacteriuria] if she was not pregnant). As she is pregnant and you do not know based on this note her GBS status, you could not report O99.820 either.

So, you can go back to the record or the provider and get more information as to the patient’s status at the time of this visit. The note does say labs done and within normal limits. If you are trying to find a diagnosis to order the GBS screening, you should report Z36.85 (Encounter for antenatal screening for Streptococcus B).