Ob-Gyn Coding Alert

Question: A patient who had problems breastfeeding their newborn came to see our ob-gyn. What diagnosis code should I use?

Kentucky Subscriber

Answer: If the care involves counseling the patient on techniques and reassurance, you will report Z39.1 (Encounter for care and examination of lactating mother). You do not need any other additional counseling code.

If on the other hand, the patent presents with a problem with the breast or an issue with lactation perse, you would instead assign code O92.- (Other disorders of breast and disorders of lactation associated with pregnancy and the puerperium).

Watch out: You should not report P92.1 (Regurgitation and rumination of newborn), P92.2 (Slow feeding of newborn), P92.8 (Other feeding problems of newborn), or P92.9 (Feeding problem of newborn, unspecified) for assistance given to and billed under the mother’s medical record.