Chapter 15 Part 5

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 Set of rules: Multiple Gestations (Category O30)


Example: A patient is pregnant with triplets and has three separate placentas and amniotic sacs. The pregnancy is in the first trimester. The correct code assignment would be O30.101 (Triplet pregnancy, trichorionic/triamniotic, first trimester).

Set of rules: Obstetric Lacerations (Category O70 and O71)


Example: A patient experiences a tear during delivery that involves the fourchette, vaginal mucosa, and underlying muscles but does not extend to the anal sphincter. The correct code assignment would be O70.0 (First-degree perineal laceration).

Set of rules: Monoamniotic and Monochorionic Gestations


Example: A patient is pregnant with twins who are developing within a single amniotic sac and sharing a single placenta. The correct code assignment would be O30.102 (Twin pregnancy, monoamniotic/monochorionic, second trimester).

Set of rules: Peri-urethral Lacerations (Code O71.82)


Example: A patient experiences a tear during delivery that involves the vulva and tissues around the vaginal opening, but does not involve the muscles or the urethra. The correct code assignment would be O71.82 (Other specified trauma to perineum and vulva) to describe the peri-urethral tear.

Set of rules: Postpartum Complications


Example: A patient is admitted for routine postpartum care following a delivery outside the hospital with no complications noted. The principal diagnosis code assigned would be Z39.0 (Encounter for care and examination of mother immediately after delivery).

Set of rules: Pregnancy-associated Cardiomyopathy (Code O90.3)


Example: A patient develops cardiomyopathy in the third trimester of pregnancy but the condition continues to progress months after delivery. The cardiomyopathy is attributed to pregnancy and the patient did not have pre-existing heart disease. The correct code assignment would be O90.3 (Pregnancy-associated cardiomyopathy).

Set of rules: Admission for Routine Postpartum Care


Example: A mother delivers outside the hospital and is admitted for routine postpartum care with no complications noted. The principal diagnosis code assigned would be Z39.0 (Encounter for care and examination of mother immediately after delivery).

Set of rules: Secondary Diagnosis Reporting


Example: A patient is admitted for a surgical procedure unrelated to a previous history of varicose veins. The patient had varicose veins develop one month after delivering a baby. The physician attributes the varicose veins to the recent pregnancy, which continue to be painful. The correct code assignment would be O87.4 (Varicose veins of the lower extremity in the puerperium) to indicate the association with the recent pregnancy.

It's important to note that these examples are for illustrative purposes and actual code assignment should be based on the specific documentation provided and adherence to official coding guidelines.




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