Ob-Gyn Coding Alert

Question: My physician performs a fern test on a patient, trying to rule out rupture of membranes. What diagnosis code applies?

Mississippi Subscriber

Answer: If the test result proves positive, then you should report 658.13 (Premature rupture of membranes with antepartum condition or complications). Otherwise, use V89.01 (Suspected problem with amniotic cavity and membrane not found), provided the patient showed no verifiable signs or symptoms.

Supplement: If the physician found fluid, but the patient did not rupture her membranes and was not in labor, report 623.5 (Leukorrhea, not specified as infective) as secondary diagnosis to the primary diagnosis 648.93 (Other current conditions classifiable elsewhere, but complicating pregnancy; antepartum condition or complication).

Keep in mind: If the patient is at her term, you will not likely be reimbursed extra to rule out labor.

Red flag: Coding for a fern test (Q0114) must indicate that the physician -- not the lab -- actually performed this Clinical Laboratory Improvement Amendments (CLIA) waived procedure.

-- The answers for Reader Questions and You Be the Coder provided by Melanie Witt, RN, CPC, COBGC, MA, an ob-gyn coding expert based in Guadalupita, N.M.