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Posted By Angie Bouchard on 05-23-2019, 10:59:49 in Ob-Gyn
Hi Melanie,
I am unsure whether to bill this as a twin delivery (both delivered) or with a modifier 22 (due to attachment/delivered with placenta). Please see the following documentation/pathology for delivery:

Progress Note DX: TRAP Sequence: Seen by MFM and UT Fetal Center. Was told no need for further fu with Fetal Center as acardiac twin small in size and no c/f heart failure at this time in pump twin. Records from Fetal Center reviewed. 5/1 MFM sono pump twin cephalic with posterior fundal placenta, left, appropriate growth, no e/o growth of acardaic twin which is superior maternal R. IGS appropriate.

Delivery Note: 29yo now G1P0101 delivered a viable male infant via term spontaneous vaginal delivery over intact perineum. Head and shoulders delivered without difficulty. APGARs 7/8, weight 2510g. No nuchals, no meconium. DCC performed. Infant handed off to the waiting NICU staff for evaluation after DCC. Placenta delivered intact, spontaneous, 3vc. Acardiac twin delivered with the placenta without difficulty. Both were sent to pathology for evaluation. EBL 250cc with adequate hemostasis achieved with 30U IV pitocin. Second degree midline perineal laceration repaired with 2-0 vicryl on CT1 under epidural anesthesia. Mother and baby in stable condition.

Nurse Note of Delivery: Pitocin augmentation for SROM at 0330. Progressed quickly after epidural placed and comfortable with epidural. Dr *** called at 8cm and present for complete and pushing. NICU in attendance for known 35 4/7 week gest and Trap syndrome of twin B with known acardiogenesis. Viable male delivered by NSVD at 2355, spontaneous cry. Placed on maternal abd with further stim and bulb suction from NICU staff. APGARs 7/8 and transferred to NICU for low blood sugars. Placenta delivered spont with attached products of conception at 2359. Pt did ask to see and was shown by Dr ***. Bleeding minimal now and family here and happy.

PLACENTA PATHOLOGY: PLACENTA, 35 4/7 WEEK GESTATION, SPONTANEOUS VAGINAL DELIVERY
- TWIN PLACENTA WITH THIRD TRIMESTER MORPHOLOGY AND ACCELERATED VILLOUS MATURATION
- WEIGHT: 425 GM (< 10TH PERCENTILE)
- ORGANIZING FIBRIN THROMBI IN CHORIONIC PLATE AND MEMBRANOUS CHORIONIC VESSELS
- AMNION NODOSUM
- FETAL MEMBRANES ARE FREE OF INFLAMMATION
- TRIVASCULAR UMBILICAL CORD (PLANCENTA A)
- SINGLE UMBILICAL ARTERY (PLACENTA B)
B. FETUS, DELIVERY
- ACARDIAC TWIN
- CLUB FOOT (BY GROSS IDENTIFICATION)


Thank you very much!

Kind regards,
Angie
Comments (1)
Posted By Melanie Witt on 05-23-2019, 15:31:31
Hard call on this one, but I think it is simpler to bill it as two vaginal deliveries with outcome one born alive, note born dead.
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