I notice E/M vs initial pregnancy visit gets a bit confusing. Especially what diagnosis to use. Our provider coded dx of " amenorrhea " and he is confirming pregnancy with ultrasound. Should we be using N91.2 or confirmation of pregnancy?
38-year-old G4, P2 aborta 1 had spontaneous abortion at 11 weeks I did do a D&C at that time it was in November of last year she is now currently pregnant her last menstrual period was 311 and she has significantly no complaints however we will plan to refer her to a perinatologist today I scanned her and she has a gestational age of 9 weeks and 4 days with an EDC of 12. By her last menstrual period and her due date is 1218 I will go by the. The last 2 pregnancies are normal all babies weighed less than 8 pounds
The last child had craniosynostosis and had to have surgery done.
She also has some kind of a discharge examined her there was no evidence of any vaginal erythema or unusual discharge however I did a new swab on the patient
She will be placed on vitamins and folic acid. Lab work done and come back to me in 2 weeks
38-year-old G4, P2 aborta 1 had spontaneous abortion at 11 weeks I did do a D&C at that time it was in November of last year she is now currently pregnant her last menstrual period was 311 and she has significantly no complaints however we will plan to refer her to a perinatologist today I scanned her and she has a gestational age of 9 weeks and 4 days with an EDC of 12. By her last menstrual period and her due date is 1218 I will go by the. The last 2 pregnancies are normal all babies weighed less than 8 pounds
The last child had craniosynostosis and had to have surgery done.
She also has some kind of a discharge examined her there was no evidence of any vaginal erythema or unusual discharge however I did a new swab on the patient
She will be placed on vitamins and folic acid. Lab work done and come back to me in 2 weeks