Wiki How would you dx code this?

[EikaMTGQueen]

Reason for Study: Dilation and effacement

Reason For Visit: CONTRACTIONS

Limited pelvis OB ultrasound transabdominal June 12, 2013

Comparison: Pelvic ultrasound January 21, 2013.

Indication: Twins with known demise

Technique: Real-time grayscale ultrasound imaging of the pelvis was
performed transabdominally.

Findings:

Transabdominal: Exam is limited as the patient was quickly taken to
the operating room for C-section. Treating physician was present for
the exam. Prior ultrasound had described triplets at that time.

Patient has known twin pregnancy. Reportedly the demise of one twin is
known. One fetus is reported to to be in the cervix. No images with
fetal heart beats are available for review so unable to confirm which
fetus lacks a heartbeat. Anterior placenta. Question placental
abruption. Reportedly the second twin had a visualized heart beat with
posterior placenta, not well-seen on available images.

Conclusion:
1. Limited exam due to patient and fetus condition. One fetus appears
to be in the cervix.

 

[Lynda Wetter]

Reason for Study: Dilation and effacement

Reason For Visit: CONTRACTIONS

Limited pelvis OB ultrasound transabdominal June 12, 2013

Comparison: Pelvic ultrasound January 21, 2013.

Indication: Twins with known demise

Technique: Real-time grayscale ultrasound imaging of the pelvis was
performed transabdominally.

Findings:

Transabdominal: Exam is limited as the patient was quickly taken to
the operating room for C-section. Treating physician was present for
the exam. Prior ultrasound had described triplets at that time.

Patient has known twin pregnancy. Reportedly the demise of one twin is
known. One fetus is reported to to be in the cervix. No images with
fetal heart beats are available for review so unable to confirm which
fetus lacks a heartbeat. Anterior placenta. Question placental
abruption. Reportedly the second twin had a visualized heart beat with
posterior placenta, not well-seen on available images.
Conclusion:
1. Limited exam due to patient and fetus condition. One fetus appears
to be in the cervix.

If there is a reportable cpt here....Documentation seems a little sketchy with no real difinitve findings. I would default back to the Indication of fetal demis. Everything highlighted above is worded in a doubtful manner.
Just my opinion.

 

[erjones147]

Personally, I would not code this. Either there is "known demise" or there is not. Somebody is going to have to make up their mind and come off of words like "reportedly" and "question."

 

[Rbmoorecpc]

Hi Erica, based the current documentation, there are so many missing pieces that it would impossible to code a dx. There is no indication of weeks gestation, the author went from triplets to twins, is this premature labor as on fetus is already in the cervix, etc. there are so many variables missing. Not code -able in my opinion.

 

[Lynda Wetter]

Hi Erica, based the current documentation, there are so many missing pieces that it would impossible to code a dx. There is no indication of weeks gestation, the author went from triplets to twins, is this premature labor as on fetus is already in the cervix, etc. there are so many variables missing. Not code -able in my opinion.

Yes, I agree with Rose. Like I said in my post "IF this is even reportable with a CPT"
Everything the provider is saying is not in a difinitive manner. No clear cut dictation for cpt or icd-9.