Wiki Help with Diagnosis Code

[TMB1965]

If the provider documents the dx as listed below, and the patient is 19 and pregnant for the first time would you just use the normal pregnancy code & a supervision code with limited prenatal care even though he didn't document supervision or primigravida? Not sure what dx codes I should use, so any help would be greatly appreciated.

1. 36 4/7 weeks, stable pregnancy
2. no ROM
3. Limited prenatal care

 

[MFMcoder]

Supervision of Primigravida is for an elderly mother-to-be, or at the age of 35 years and older or for a young mother-to-be, age under 16 at the time of delivery. A 19 year old would not fall into either of these.
Also it is contradictory to code a routine outpatient visist when no complications are present with a complication. You should use a code from Z34 category for a "stable pregnancy". If the limited prenatal care is truly complicating the pregnancy you would need to use a code from Chapter 15. Please review the notes regarding Chapter 15 in the Official Guidelines for Coding and Reporting to understand. You should ask the provider if the late care is complicationg the pregnancy and being managed or treated somehow. If not it should be a Z34. Otherwise use a code in the O09.3x category.

 

[TMB1965]

Thank you for your help!