Wiki New to coding OB/GYN

Create Wiki
B

BeckyL1958

Guest
Messages
21
Best answers
0
I am seeing a lot of chief complaints of "leaking fluid" and or "cramping" most of these turn out that there is no amniotic fluid leaking and patient is not in active labor. I was wondering what the best code to use is for the leaking. I've been using abdominal pain for the cramping unless I see that patient was actually having contraction. I just don't want to put "premature rupture of membranes" if that has not actually happened. Any help or advice is greatly appreciated.
 
I am not sure what you want to code for if the patient is not leaking fluid? If a patient comes in with a complaint that isn't found, our doctors either code it as just a routine visit (V22.0 or V22.1) or use the code V65.5 - Worried well. You would only code premature rupture of membranes if that is what the doctor says happened. Otherwise you can't use a diagnosis code for something that was not found.

Hope I understood your question correctly and this helps!
 
I wouldn't use 623.5. That is for Leukorrhea or a vaginal discharge and unless the doctor says that is what the patient is experiencing, this would not apply to a pregnant patient who thinks she is leaking amniotic fluid. If she is indeed leaking fluid, code 658.1x would be the code. However, as Becky said most of the time the patient isn't leaking amniotic fluid so you would not code it as leaking flluid and you can't code something as suspect or probable.
 
new to OB/gyn

For the leaking fluid you could use v89.01, Suspected problem with amniotic cavity and membrane not found. All of the V89 codes are for suspected problems, not found. Check it out.:)
 
Reply

You would only use V22.2 for a routine visit where the patient is pregnant, and not as the primary DX.
 
To use V22.2 as a secondary dx code the provider must document that the current condition is NOT affect the pregnancy. Without this being documented the code must select a code from the 630-677 range for any visit when the patient is pregnant with a presenting symptom or condition ornV22.1 or V22.0 if just for supervision.
 
ob

very new to ob/gyn...gyn seems much easier to code however I have the biggest challenge with ob's.....are they to be sent per visit? I have been told so many different ways to send the claims. Most insurance want to post delivery but initial to be billed..my question is if we are having to wait how are we showing all dates of service if they pay global? I hope I don't sound stupid...I have put a lot of study time in this and unfortunately in our area ob/gyn is not a big field that you can find experience people in to help with coding billing and sending claims. Any advice will be helpful...Thanks, Texas Heat!
 
You must log in or register to reply here.
Top