Ob-Gyn Coding Alert

At the end, the provider stated, “Patient temp 100 degrees F skin, patient tachycardic throughout the procedure plan to continue antibiotics for 24 hours.” On these, I came up with O75.2 and O89.82 with R00.0. Is that correct? Here’s the operative report:

Preoperative Diagnosis: Patient is an 29 y.o. G1P0 at 40w1d persistent cat II tracing, remote from delivery

Principal Problem:

Persistent cat II tracing, remote from delivery
Thick meconium
OP position and asynclitic
Insufficient epidural

PostoperatIve Diagnosis:
same

Procedure: Primary Low Transverse Cesarean Section

After informed consent was obtained, the patient was taken to the operating room where the dosing of Epidural anesthesia was found to be inadequate. Patient was then prepared and draped in the normal sterile fashion in the dorsal supine position with a leftward tilt. A time out was held, and the patient and procedure were confirmed.

General anesthesia was induced and immediately a Pfannenstiel skin incision was then made with the scalpel and carried through to the underlying layer of fascia. The fascia was incised in the midline with the scalpel and extended laterally bluntly. The rectus muscles were then separated in the midline bluntly, and the peritoneum identified, tented up, and entered blunt dissection. The peritoneal incision was then extended superiorly and inferiorly bluntly with good visualization of the bladder. The bladder blade was then inserted, a bladder flap was not created.

The lower uterine segment was incised in a transverse fashion with the scalpel. The uterine incision was then extended laterally digitally. The bladder blade was removed, then the fetus was noted to be in cephalic presentation. There was difficulty elevating the fetal head out of the pelvis and the RN had to glove and perform a vaginal exam to apply pressure to gently elevate the head out of the pelvis so the head could be reached and brought to the incision. Gentle fundal pressure was applied once the head was brought into the incision and infant delivered atraumatically. Baby was noted to be left occiput position (LOP) position.

The cord clamping was immediately double clamped and cut. The neonate was handed off the field to the awaiting neonatal team. Cord gases and blood collected. The placenta was then removed, the uterus was exteriorized, and cleared of all clots and debris. The fibroid was noted to be approx 7x8cm right fundal. The uterine incision was repaired with 1 Vicryl in a running, locked fashion. A second layer of the same suture was used in an imbricating fashion to obtain excellent hemostasis. The abdominal cavity was irrigated, and the uterus was replaced into the abdomen. The gutters were cleared of all clots and debris the hysterotomy site was noted to be hemostatic. The fascia was then reapproximated with 1 Vicryl in a running fashion. The subcutaneous tissue was closed with 3-0 vicryl in a running fashion. The skin was closed with 4-0 Monocryl in a subcuticular fashion noting excellent hemostasis. Sponge, lap and needle counts were correct times two. Mepilex placed over incision.

Of note, per anesthesia, patient temperature 100 degrees F skin temp, patient tachycardic throughout procedure, plan to continue antibiotics x24 hrs.

Postpartum hemorrhage (EBL >1000mL): None
Complications: None; patient tolerated the procedure well.
Disposition: Hemodynamically stable.
Condition: Atable
Follow up: Will follow patient while inpatient

Illinois Subscriber

Answer: Your primary diagnosis will be the OP presentation, as this is why they did the cesarean. That code is O64.0xx0 (Obstructed labor due to incomplete rotation of fetal head, not applicable or unspecified).

It also appears that there was meconium in the amniotic fluid, so you could also report O77.0 (Labor and delivery complicated by meconium in amniotic fluid).

The insufficient epidural was not the reason for the cesarean, and O89.82 is not a valid code, so it is unsure what you are reporting this to indicate.

The mother did have a fever during labor (O75.2, Pyrexia during labor, not elsewhere classified) and tachycardia (R00.0, Tachycardia, unspecified).

While there was a Cat II tracing, this is considered indeterminate as to fetal acidosis, so you could not report a non-reassuring fetal heart rate.