Hello,
I am in need of some help of when to bill the admit charge for an induction due to patient being 40 weeks and also has Chronic Hypertension.
There is list of Medical Complications that are listed in the EXCLUDES Section:
I am hoping to see if someone can help me to understand.
The example of the note is below:
Patient is a 38 y.o. G2P1001 female with EDC September 1, 2021 is 40-2/7 weeks gestation Gestational Age: <None> who is being admitted for induction of labor. Her current obstetrical history is significant for hypertension not requiring medication advanced maternal age bacterial vaginosis currently being treated with Flagyl anxiety treated with Vistaril history of a prior LEEP procedure. Patient reports no complaints. Fetal Movement: normal.
Patient has had poor prenatal care was seen originally for 2 visits by Dr. XXX and then was seeing Dr. XXX until approximately 34 weeks at which time Dr. XXX bulimic had discharged her.
Assessment/Plan:
Assessment
Gestational Age: <None>.
38-year-old gravida 2 para 1 at 40-2/7 weeks gestation
Obstetrical history significant for chronic hypertension
Advanced maternal age
History of a LEEP procedure no longer relevant
Mild thrombocytopenia in early pregnancy which is resolved
Poor prenatal care.
Plan
Risks, benefits, alternatives and possible complications have been discussed in detail with the patient. Pre-admission, admission, and post admission procedures and expectations were discussed in detail. All questions answered, all appropriate consents will be signed at the Hospital. Admission is planned for today.
Patient is admitted for induction of labor at a detailed discussion of the use of Cytotec which is off label use for induction however there is substantial clinical data to support its use
I discussed risks of induction to include include uterine hyperstimulation with potential for fetal distress the need for continual monitoring the patient understands and gives consent
She desires to breast-feed and desires epidural will treat for GBS presumptively
Dr. XXXX
I am in need of some help of when to bill the admit charge for an induction due to patient being 40 weeks and also has Chronic Hypertension.
There is list of Medical Complications that are listed in the EXCLUDES Section:
I am hoping to see if someone can help me to understand.
The example of the note is below:
Patient is a 38 y.o. G2P1001 female with EDC September 1, 2021 is 40-2/7 weeks gestation Gestational Age: <None> who is being admitted for induction of labor. Her current obstetrical history is significant for hypertension not requiring medication advanced maternal age bacterial vaginosis currently being treated with Flagyl anxiety treated with Vistaril history of a prior LEEP procedure. Patient reports no complaints. Fetal Movement: normal.
Patient has had poor prenatal care was seen originally for 2 visits by Dr. XXX and then was seeing Dr. XXX until approximately 34 weeks at which time Dr. XXX bulimic had discharged her.
Assessment/Plan:
Assessment
Gestational Age: <None>.
38-year-old gravida 2 para 1 at 40-2/7 weeks gestation
Obstetrical history significant for chronic hypertension
Advanced maternal age
History of a LEEP procedure no longer relevant
Mild thrombocytopenia in early pregnancy which is resolved
Poor prenatal care.
Plan
Risks, benefits, alternatives and possible complications have been discussed in detail with the patient. Pre-admission, admission, and post admission procedures and expectations were discussed in detail. All questions answered, all appropriate consents will be signed at the Hospital. Admission is planned for today.
Patient is admitted for induction of labor at a detailed discussion of the use of Cytotec which is off label use for induction however there is substantial clinical data to support its use
I discussed risks of induction to include include uterine hyperstimulation with potential for fetal distress the need for continual monitoring the patient understands and gives consent
She desires to breast-feed and desires epidural will treat for GBS presumptively
Dr. XXXX