raidaste
Guest
Delivery Note:
Patient is a 24 yr old gravida 2, para 1 female who was admitted for an elective induction of a fetal distress at 16 to 18 wks. The patient had an abnormal alpha-fetoprotein. The mother was visiting the Maternal/Fetal Med clinic for further ultrasound eval and the intrauterine fetal demise was found. When the patient was at the office 2 weeks ago, she had good heart tones and growth. The baby has seemed to expire within these last 2 wks according to size. There was a large cystic hyroma noted on the ultrasound. Other organs were somewhat difficult to identify due to the fetal death. The pt was admitted for Cytotec induction in the afternoon and I believe she rec'd. 3 or 4 doses of Cytotec.
At 0200 hrs the patient had an increase in pelvic contractions and pressure and at about 0300 hrs, she delivered the baby and shortly after, an intact placenta. Bleeding was minimal. At this time, the patient is doing well. The fundus is firm. The patient is interested in the baby's gender and trying to know the genetic outcome and we will attempt to obtain appropriate tissue samples to send for chromosomes if they can be grown and also a path assessment of baby.
There's discussion on what can be charged and what occurred. I was going between 59855 or just the 59200 but I can't decide. Any help would be appreciated.
Patient is a 24 yr old gravida 2, para 1 female who was admitted for an elective induction of a fetal distress at 16 to 18 wks. The patient had an abnormal alpha-fetoprotein. The mother was visiting the Maternal/Fetal Med clinic for further ultrasound eval and the intrauterine fetal demise was found. When the patient was at the office 2 weeks ago, she had good heart tones and growth. The baby has seemed to expire within these last 2 wks according to size. There was a large cystic hyroma noted on the ultrasound. Other organs were somewhat difficult to identify due to the fetal death. The pt was admitted for Cytotec induction in the afternoon and I believe she rec'd. 3 or 4 doses of Cytotec.
At 0200 hrs the patient had an increase in pelvic contractions and pressure and at about 0300 hrs, she delivered the baby and shortly after, an intact placenta. Bleeding was minimal. At this time, the patient is doing well. The fundus is firm. The patient is interested in the baby's gender and trying to know the genetic outcome and we will attempt to obtain appropriate tissue samples to send for chromosomes if they can be grown and also a path assessment of baby.
There's discussion on what can be charged and what occurred. I was going between 59855 or just the 59200 but I can't decide. Any help would be appreciated.