Wiki Complication Assumption

[raidaste]

I'm needing a little help understanding the rules of OB care. If a patient has a condition such as, bipolar or tobacco use, do we assume that it's complicating pregnancy and code the 648.4x or 649.0x codes or does the physician have to say that the condition is complicating the pregnancy? Any help with this would be great.

 

[Anastasia]

This should be documented by the physician in the patient's prenatal record. Never assume.

 

[mitchellde]

You always code the 648.xx or any other chapter 11 code for a woman that is pregnant. You only use the condition and V22.2 when the provider documents that the condition is not affecting the management of the pregnancy. This is covered in the coding guidelines.