Wiki dx help with pregnant trauma patient

[ggparker14]

I have a pregnant patient that tripped and fell and sustained a foot sprain. What is the correct way to code trauma for a pregnant patient?


Thanks for any help

 

[hewitt]

Would help to know if it is suspect/evidence that the baby may be in trouble? Is the mother showing unusual symptoms/signs as a result of the fall? Was there testing done to validate all is well? If so, what symptoms/signs prompted the testing?

 

[kellyobenour@yahoo.com]

V22.2

It is my understanding that when the encounter is NOT related to the pregnancy in any way, that you code V22.2 in addition to the reason for the visit. It is the physician's responsibility to state the condition being treated is not affecting the pregnancy.

You can reference pg 14 in the 2012 ICD9 manual. Under Chapter 11 guidelines. A. 1.

 

[charissesimone]

I have a pregnant patient that tripped and fell and sustained a foot sprain. What is the correct way to code trauma for a pregnant patient?


Thanks for any help

If the trauma did not cause the labor such as sprain or fracture(based off documentation in medical chart).

Then you would code the fracture first then pregnancy codes secondary. "V22.2 " is Not appropriate as that only means "Pregnancy state NOS"otherwise no other info of pregnancy status. But since you have the trauma code already; you need to read the pt's chart to determine if the sprained injury affect the pregnancy( example: Did the fall from the sprain foot caused any labor? If so the the codes in Chapter 11-would be coded first ( called Principal Diagnosis Inpatient coding.), then the sprain would be coded secondary with E-Codes, Activity, & Place occurrence codes(if stated.)

 

[mitchellde]

If the provider does not specify that the pregnancy is incidental you cannot use V22.2 the. Guidelines specify that it is the providers responsibility to specify that the current condition is not complicating the management of the pregnancy. The correct way to code is to use the 648.xx code first followed by the trauma. Look in the alpha under pregnancy, complicated by, trauma, or injury.

 

[kak6]

Absolutely what mitchellde said, I agree.