Wiki Pregnancy Complication or Not??

[Daisy29]

Hello,

This forum has been such a huge help for me as a brand new coder!

I am hoping that someone here can help me. I am having a hard time wrapping my head around coding pregnancy complications.

For example, a pregnant woman came in with hyperemesis and dehydration. The H&P lists GERD under the past medical history. She is currently on daily medication for the GERD.

I have my admit & primary DX as O21.1 (hyperemesis gavidarum with metabolic disturbance).

This is where it gets tricky. I do not know if I need to add GERD as a complication of pregnancy (O99.611- disorder of digestive system complicating prgnancy + K21.9 gerd) or if I just need to code the GERD alone. The MD does not state that it complicates pregnancy, but once again she is on DAILY medicine for it based on her medication list.

I FEEL LIKE IF I CAN GET THIS FIGURED OUT I WILL KNOW WHAT DIRECTION TO GO IN WHEN CODING THESE KINDS OF CHARTS.

Any help would be greatly appreciated.

 

[mitchellde]

She has no issues documented as being related to the GERD, the provider did not treat the GERD, therefore I would not cod at all. It was not relevant to this encounter.

 

[Daisy29]

she has no issues documented as being related to the gerd, the provider did not treat the gerd, therefore i would not cod at all. It was not relevant to this encounter.

I am still trying to wrap my head around this as well, but we have to code all chronic conditions, especially if the pt is taking medication for it. This is for an observation acct.

 

[mitchellde]

You do not have to code all chronic conditions, you code that which is documented by the provider as managed controlled or treated at the encounter. The GERD was mentioned by the patient as a part of history. Who is stating that you must code all chronic conditions?

 

[Daisy29]

You do not have to code all chronic conditions, you code that which is documented by the provider as managed controlled or treated at the encounter. The GERD was mentioned by the patient as a part of history. Who is stating that you must code all chronic conditions?

It is a policy in our health system.

If the H&P, d/c summary, ed report, or anesthesiology note has a chronic condition listed (GERD, hyperlipidemia, hypertension, hypohtyroidism ect.) I have to code it since they take medicine for it. I guess it is because they have to continue the medication while under care? Who knows.

So if a PT comes in for a cholecystectomy, and they have any of the conditions I listed above, for example, I would have to code that and the symptoms that are present, such as RUQ pain.

Needless to say, I am very confused because I was taught differently in school and I didn't do it this way on my certification exams.

 

[pookergirl]

Same here with coding all chronic conditions on observation patients

I was told the same thing, code everything in the PMH if they still have it or are being treated for it. But I wouldn't code a symptom, like abdominal pain, if the patient is being treated for a definitive diagnosis such as cholecystitis, etc.

I'm confused because I code lab and x-ray orders and all order says is pregnancy 28 weeks, HTN, check AFI, check dates and size. I don't know how to code the HTN because it's not stated either way if it's pre-existing or pregnancy-induced.