Wondering what everyone's opinion is regarding using pregnancy complication codes when a patient has a condition even if the documentation does not specifically state that the pregnancy is complicated or management is effected by the condition. For example:
1. Patient is a smoker but documentation only reflects that possible complications are reviewed with the patient. No mention that a complication is there or imminent.
2. Patient has hypothyroidism and documentation only indicates that blood shall be drawn every trimester.
What type of verbiage or anything else would one look for to determine if a complication truly exists. Or should there be an "assumption" that all conditions effect the pregnancy? I have read the ICD guidelines and don't feel they are clear enough to answer this question.
Thanks much!
1. Patient is a smoker but documentation only reflects that possible complications are reviewed with the patient. No mention that a complication is there or imminent.
2. Patient has hypothyroidism and documentation only indicates that blood shall be drawn every trimester.
What type of verbiage or anything else would one look for to determine if a complication truly exists. Or should there be an "assumption" that all conditions effect the pregnancy? I have read the ICD guidelines and don't feel they are clear enough to answer this question.
Thanks much!