Wiki Counseling patient on options for pregnancy

[BPalumbo1129]

A patient presents to our practice with an unexpected pregnancy. The U/S reveals a twin gestation at 7+ weeks. Pt has family history of twin gestations and is unsure if she wants to proceed with the pregnancy. Provider counsels patient on options: adoption, medical/surgical abortions w/ risks associated. Patient will contemplate options and discuss with partner. Lab script given for CBC, blood group and Rh. A gyn exam is not performed. Since the patient is unsure about how to proceed with pregnancy, the OB episode cannot begin, so a problem related office visit - E/M CPT code 9921- (patient is established) is to be billed. Would ICD-10 codes Z71.89 (other specified counseling) and Z64.0 (Problems related to unwanted pregnancy) be appropriate to report for this visit? I appreciate any insight/feedback about this matter. Thanks!!

Bernadette Palumbo, CPC

 

[pclaybaugh]

Hi, as you state the patient isn’t sure, perhaps leave off the Z-code for the unwanted pregnancy. This appears to be a confirmation of pregnancy visit, so Z32.01 seems appropriate.

 

[rstroup]

I would use Z32.01 as your primary DX and Z71.89 as a secondary dx.

--
Ryan Stroup, CPC

 

[BPalumbo1129]

So even if a urine pregnancy test is not performed, we could still report a confirmation of pregnancy diagnosis based on the U/S revealing a 7 week twin gestation, correct?

 

[nielynco]

So even if a urine pregnancy test is not performed, we could still report a confirmation of pregnancy diagnosis based on the U/S revealing a 7 week twin gestation, correct?

Yes, the US has confirmed pregnancy.

 

[BPalumbo1129]

Great! Thank you for your responses.