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69 Cards in this Set

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puerperium
period from the termination of labor until the complete involution of the uterus. Usually 42 days
Codes from Chapter 11 (complications of child birth, pregnancy, child birth, and puerperium)
have sequencing priority over all other codes
leiomyoma
uterine fibroids

coded according to where they are located. Submucosa leimyoma are beneath the endometrium. subserous leimyoma are located beneath the surface of the uterus
preeclampsia
Preeclampsia is when a pregnant woman develops high blood pressure and protein in the urine after the 20th week (late 2nd or 3rd trimester) of pregnancy.
hyperemesis gravidarum
Hyperemesis gravidarum is extreme, persistent nausea and vomiting during pregnancy that can lead to dehydration.
V23
Supervision of high risk pregnancy
elderly primigravida
patient's first pregnancy if they are over the age of 35
younger than 16 at expected date of delivery and has complications code- young primigravida/multigravida
659.8X- other specified indications for care or intervention related to labor and delivery.

V codes are reported when there are no pregnancy complications, but still indicate the patient is at high risk due to her age.
normal delivery
650
whether the delivery is normal or complicated, a code for delivery is required
V27.0-V27.9
ARF
Acute renal failure-rapid onset. The 4th digit identifies the lesion of the necrosis.
Urge incontinence
sudden need to urinate followed by the sudden release of urine.
UTI
urinary tract infection- if the provider documents a specific organ, select a code for the specific organ instead of the code for UTI
CIN
Cervical Intraepithelial Neoplasia- an abnormal growth or premalignant cells of the cervix.
BV
bacterial vaginosis
CPP
Chronic Pelvic Pain
CKD
Chronic Kidney Disease
DUB
dysfunctional uterine bleeding- abnormal bleeding from the vagina that is due to changes in hormone levels.
ESRD
End Stage Renal Disease
LMP
Last Menstrual Period
PSA
Prostate Specific Antigen
SUI
- stress incontinence occurs with an activity such as coughing, sneezing, or exercise.
If the patient is seen for an unrelated condition (such as a fracture) while being pregnant how do you code it?
Code the unrelated condition first then put "incidental to pregnancy" V22.2
If the patient is pregnant and they are being treated for a HIV related illness
the first listed code is 647.6x followed by 042 and the codes for the HIV related illnesss
If the pregnant patient is HIV positive and their are no symptoms
Code 647.6x then V08
Pregnancy and Diabetes coding
2 codes are required: 648.0 (Diabetes mellitus complicating pregnancy followed by the code for diabetes mellitus. If they use insulin there is a third code: long-term use of insulin V58.67

DO NOT USE 250 or 249!!!!!!!!!!!!!!!!!!!!
The postpartum period is
6 weeks
If the patient delivers outside of the hospital (on the way or at home)
Do not report a delivery code use V24.0 postpatum care immediately after delivery
puerperal sepsis
An infection in the genital tract that develops during the postpartum period code it 670.2x. Put this code before the infecting organism.

if sepsis is documented code 995.92 with an additional code for the acute organ dysfunction

so the order would be 670.2x, infecting organism, 995.92, organ failure
abortions as a result of a complication in pregnancy
require an additional code from 640-648 or 651-659. when selecting the code to report the complication the fifth digit 3 is reported to indicate the antepartum condition or complication.
AGA
appropriate for gestational age
ARM
artificial rupture of membrane
CP
cephalopelvic disproportion
CS
cesarean section
EDD
Estimated date of delivery
EFW
estimated fetal weight
FAS
fetal alcohol syndrome
G
Gravid (pregnant)
HSV
herpes simplex virus
LGA
large for gestational age
PROM
Premature Rupture of Membranes
arche/o
first
crypt/o
hidden
bilateral ulcers
with the same stage are coded with one code for location and one for severity.

with different severity are coded with one code for the site and 2 codes to identify each stage

sequence the most severe ulcer first
PPD
Purified protein derivative- skin test for TB
SLE
systemic lupus erythematosus
generalized OA
involves more than one joint
primary OA
has no known cause
Secondary OA
develops as a result of injury or disease.
pathologic fractures
occurs in an area of weaken boned. After active treatment report the appropriate after care V code. These can be found by looking up "Aftercare"
injury coding
code the most serious injury first, superficial injuries are not coded when there is a more serious injury at the same site.
when coding a dislocation and a fracture to the same bone
code the fracture site only
fractures are coded
as long as active treatment is sought

afterwards code V54
a fracture that is infected, compound, or with a foreign body is considered
an open fracture
blistering
aka vesiculation
non-healing burns
categorized as acute burns; necrosis of burned skin is coded as this.
examples of co-morbid conditions for a burn are
diabetes mellitus, cardiovascular disorders, alcoholism, peptic ulcers, and asthma

should always be coded in addition to the burn code.
burns of multiple specified sites
used when multiple burns have been identified across multiple three digit categories (940-945) and there is not enough space on the claim form to report multiple codes
if all the burns are classified with the same 3 digit category code
then the fifth digit code "9" should be used
category 948
used to categorize burns according to the extent of the body surface covered.

4th digit categorizes the % of body surface burnt
5th digit categorizes the % of body surface with 3rd degree burns
poisoning
use the Table of drugs for code
adverse effect of a drug or chemical
use more than one code- one code reports the circumstance of the adverse effect sand the second code identifies whether the substance was in therapeutic use or suicide attempt, assault, or accident.
when coding adverse reactions to a correct substance properly administered
you will use 2 or more codes:
first use the code to identify the manifestations
the second code identifies the drug causing the reaction
when there is no documentation of symptoms with the adverse reaction
code 995.2 other and unspecified adverse effect (found under diseases anesthesia) or complication anesthesia
poisoning
the first code from the poisoning column identifies the drug
then the second code identifies the manifestation
finally an E code indicates the circumstances
complications
when the complication is the reason for the visit then a complication code is reported as the primary diagnosis

if there is an infection also code the infecting organism
A V code is always listed firs when
reporting a newborn's birth status
when the reason for the visit is the screening and the dr finds a abnormality
put the v code first
follow-up care vs aftercare
follow-up is when the fully healed

aftercare is while the patient is still healing i.e removal of stitches