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10 Cards in this Set
- Front
- Back
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Explain how to code deliveries |
All live born infants regardless of the number of weeks gestation must be coded as a delivery. For all delivery episodes a code from R17-R25 must be assigned in a primary position. R24.9 all normal delivery must only be assigned when no other code in R17-R25 is applicable. If one type of delivery method is used and is subsequently changed to another type only the method used to successfully deliver the baby is required. When coding cesarean section a code from R17 elective cesarean is for patients not in labor. A code from R18 other cesarean delivery is for patients in labour (and all emergency cesarean sections). When coding multiple deliveries (twins, triplets) each different type of delivery must be recorded with the most serious being sequenced first, where all methods of delivery are identical only one code is required |
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What is the definition of a normal delivery |
Process of giving birth without mechanical intervention with a vertex (top of head) presentation |
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What is ARM |
Artificial rupture of membranes |
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How must intravenous augmentation when in labour be coded |
When a patient has already commenced in labour and intravenous augmentation is used to stimulate uterine contraction a code from R15 other induction of labour is assigned |
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How must forceps delivery be coded |
If a type of forceps is named for cephalic delivery (R21-R24) e.g neville barnes, even though that type may normally be used for a mid forceps delivery the coder must ascertain that this is in fact the case. The type of delivery low, mid or high and not the name must be considered |
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How must face to pubes presentation be coded |
Delivery of a baby with an abnormal cephalic presentation described as face to pubes (without using instrumentation) must be coded using R23 cephalic vaginal delivery with abnormal presentation of head delivery without instrument |
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How must an episiotomy to facilitate delivery and subsequent repair be coded |
Where an episiotomy has been carried out to facilitate delivery it must be sequenced in a secondary position to the delivery code. The subsequent repair is implicit in the code and is not coded in addition. The exception is where the episiotomy has extended to a perineal tear in which case repair of Obstetric laceration must be assigned in addition |
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How must gentle cord traction for removal of retained placenta be coded |
Forms part of the management of normal delivery and cannot be classified using OPCS. Must not be confused with manual removal of placenta from delivered uterus |
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Explain how Obstetric scans must be coded |
Obstetric scans within R36-R43 ate coded for day cases and where patients are admitted solely for the procedure. When two or more codes within R37 non routine obstetric scan and R38 other non routine Obstetric scan are performed during the same scanning session R37.2 detailed structural scan must be coded. Codes in R36-R43 are always carried out using ultrasound therefore Y53 is not required. Notes must be followed for gestational age |
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How must anti-D injection following delivery be coded |
Anti-D injected prophylactically following delivery, abortion or miscarriage must be coded X30.1 injection of rh immune globulin in addition to the appropriate code for the delivery, abortion or miscarriage. Anti-D injections must be recorded each time they are performed |
