Wiki Diagnosis for NST

[ELBrock]

The NST record states the indication is "Leaking Vaginal Fluid."
NST results were "reactive."
Patient discharged to home.

What would you code as the reason for the visit?
I'm thinking either O47.03 (False Labor) because the sub-description is "Threatened labor." The patient must have been thinking she had SROM, so it was a labor check?
Or I'm thinking O26.89 (Other specified pregnancy related condition) with N89.8 (other specified noninflammatory disorder of the vagina)
Or perhaps O41.8X30 (Other specified disorders of amniotic fluid and membranes)

Thank you!

 

[thomas7331]

In my opinion, there is insufficient information here to assign a code. For one thing, although it's assumed and common sense that a patient receiving a NST that is reactive would certainly be pregnant, if it is not documented then technically speaking it would not be supported. If I were unable to query the provider and had to assign something here, I think would go with your second choice O26.89/N89.8, but it would be better to have the provider supply the additional information. I don't believe the other two are appropriate without additional documentation as you're having to make too many assumptions/interpretations that aren't reflected in the record.

 

[fwnewbie]

I would definitely want the gestational age to code and since they never confirmed ruptured membranes that's out. Also SROM doesn't necessarily lead to labor, especially if it's a premature gestation, but an NST is certainly indicated if there was a rupture of membranes. So I agree that 026.89 seems the logical choice but you still need the gestational age. Just my opinion.