Wiki pregnancy in outpatient visit

[Brenda1973]

Hello, I do not have OBGYN "O code" experience. Can someone help with just basic coding of a pregnant patient with a cough. I was under the assumption that "O" codes are for complications of pregnancy and follow by the "Z" code for trimester, and trimester codes are only used on O codes. Is that correct?

In the below scenario would I code the cough (R05.9) followed by Z33.1 (pregnant state, incidental) as I don't see this as a complication to pregnancy, please advise, thanks!
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ASSESSMENT AND PLAN/MEDICAL DECISION MAKING
Diagnosis: 1. Acute cough

2. 16 weeks gestation of pregnancy


Orders and Instructions: Discussed with patient about possible causes. Patient with symptoms that have been ongoing for about 10 days. Recently with subjective fevers/chills. Symptoms worsening. Recommended in-person evaluation for lung auscultation, vitals check, and possible diagnostics. She will seek the additional care.


Follow up today (on 7/14/2024) for Urgent Care - Immediately.

Patient voiced understanding and agrees to plan. She will seek the additional care.

 

[nielynco]

Hello, I do not have OBGYN "O code" experience. Can someone help with just basic coding of a pregnant patient with a cough. I was under the assumption that "O" codes are for complications of pregnancy and follow by the "Z" code for trimester, and trimester codes are only used on O codes. Is that correct?

In the below scenario would I code the cough (R05.9) followed by Z33.1 (pregnant state, incidental) as I don't see this as a complication to pregnancy, please advise, thanks!
-----------------------------------------------------------------------------------------------------------------------------------------
ASSESSMENT AND PLAN/MEDICAL DECISION MAKING
Diagnosis: 1. Acute cough

2. 16 weeks gestation of pregnancy


Orders and Instructions: Discussed with patient about possible causes. Patient with symptoms that have been ongoing for about 10 days. Recently with subjective fevers/chills. Symptoms worsening. Recommended in-person evaluation for lung auscultation, vitals check, and possible diagnostics. She will seek the additional care.


Follow up today (on 7/14/2024) for Urgent Care - Immediately.

Patient voiced understanding and agrees to plan. She will seek the additional care.

First reference the ICD10 guidelines for coding O codes (Chapter 15. A. 1). "Should the provider document that the pregnancy is incidental to the encounter, then code Z33.1, Pregnant state, incidental, should be used in place of any chapter 15 codes. It is the provider’s responsibility to state that the condition being treated is not affecting the pregnancy"

Second, this sounds like it was a phone call, not an in-person visit. Was this then followed up with an appointment with this provider or provider's office within 24 hours of the call (or the next available appointment related to the complaint)? If so you bill only for the visit.