Wiki ultrasound codes for OB

[sandyjean62]

I am a ultrasound tech and doing the billing and coding course. The question I have is for Ultrasounds I was taught to use z36.8a or whatever code needed followed by the weeks gestation as the second code then follow with any other code needed. was double checking this . One person is telling me I can put the codes for the problems such as gestational diabetic or anything like that first. wasn't sure if that was correct . Can someone help me ??? thanks

 

[thomas7331]

I'd refer you here to section IV.G of the ICD-10 guidelines:
List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions.

So the coding of the first diagnosis will depend on the reason for the encounter, i.e. why the ultrasound was ordered. If it is being done as a routine screening, then Z36.8A would be appropriate as the first diagnosis. If it's being done due to an identified symptom or problem that requires investigation, then you'd use the code for that problem as your first diagnosis.

 

[sandyjean62]

I'd refer you here to section IV.G of the ICD-10 guidelines:
List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions.

So the coding of the first diagnosis will depend on the reason for the encounter, i.e. why the ultrasound was ordered. If it is being done as a routine screening, then Z36.8A would be appropriate as the first diagnosis. If it's being done due to an identified symptom or problem that requires investigation, then you'd use the code for that problem as your first diagnosis.

so where would you put the weeks gestation ?? I know you have to have that was wondering the order??

 

[thomas7331]

so where would you put the weeks gestation ?? I know you have to have that was wondering the order??

The Z3A codes are for additional information, so they would never be used as the primary code since they do not indicate a reason for an encounter. You can list them anywhere else - the order is not important beyond the first diagnosis code which needs to be your condition that is 'chiefly responsible for the services provided'.