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Posted By Maria on 02-10-2021, 06:53:13 in Ob-Gyn
Hello Melanie,

Pt presents for version, after ultrasound fetus in now Cephalic position.

1) What would be the correct ICD 10 codes. Breech, as it was the reason the patient presented for care. ?
2) Procedure not carried out? z53.09
3) Should elevated BP coded?
4)Should obesity be coded? As they were just mentioned in note. "Mildly elevated BP with risk factor of obesity" But no care given.
 
History of Present Illness:
This is a 22y.o. G2P1001 at 37w2d Estimated Date of Delivery: 2/8/21 IUP presents to triage for scheduled version procedure. Last ultrasound was transverse/breech last Thursday.
Denies LOF, VB
+FM
Denies headache, visual changes, epigastric pain
Denies nausea/vomiting/diarrhea/constipation/fever/dysuria or chills
Review of Systems:
Constitutional: wnl
HEENT: wnl
Respiratory: no complaints
Cardiovascular: no chest pain
Gastrointestinal: no unusual changes
Genitourinary: no dysuria, no frequency, no urgency
Skin: no rashes or unusual changes
Neurological: no reported deficits
Endo: no complaints
Heme: no complaints
Psychiatric/Behavioral: in usual state
 
Last Filed Vitals:
Temp 96.3 °F (35.7 °C) (01/20/21 0553) Source Temporal
BP 136/76 (01/20/21 0636) Heart Rate 83 (01/20/21 0636)
Resp 18 Weight 113 kg (250 lb) (01/20/21 0603)
SpO2 98%    
Height 167.6 cm (5' 6") (01/20/21 0603)    
BMI 40.3 (01/20/21 0603)    
 
 
139/76, 117/64, 136/76
 
Physical Examination:
FHT: 140, mod variability, no decels, +accels, Cat 1
Toco: occ
Sterile Speculum Exam: defer
Sterile Vaginal Exam: defer
Bedside Ultrasound: CEPHALIC, +CA
Heart: RRR
Lungs: CTAB
Abdomen: Gravid, soft, non-tender
Skin: warm and dry
HENT: WNL
Extremities: No edema
Scotoma: denies
DTRs: +2
Clonus: 0
 

Recent WBC/Hgb/Hct/Plt/Na/K/Cl/CO2/Bun/Creat/Glucose/PT/PTT/INR lab results (may not include all current labs):
WBC Hgb Hct Plt
10.2 (01/20 0650) 10.3 (01/20 0650) 33.0 (01/20 0650) 298 (01/20 0650)
AST ALT Uric Acid BUN
17 (01/20 0650) 15 (01/20 0650) 5.4 (01/20 0650) 8 (01/20 0650)
Creat Glucose ABO/RH GBS
0.72 (01/20 0650) 87 (01/20 0650) O POS (01/20 0650)
 
 
Assessment/Plan:
This is a 22y.o. G2P1001 at 37w2d Estimated Date of Delivery: 2/8/21 IUP here for scheduled version -- cancelled due to cephalic presentation.
Mildly elevated BP with risk factor of obesity
Cat 1
GBS pos
Rh pos
 
Plan:
PEC labs
NST
 
@0655
NST Reactive
A/P:
22y.o. G2P1001 at 37w2d Estimated Date of Delivery: 2/8/21 IUP here for scheduled version -- cancelled due to cephalic presentation; elevated blood pressures - follow up BPs normal, HELLP labs normal. Maternal and fetal status reassuring.
 
Home with instructions and to follow up with OB provider tomorrow as scheduled or return as needed for worsening or persistent symptoms. Patient verbalized understanding of above. Questions answered.
 


 

 
 

Comments (2)
Posted By Melanie Witt on 02-10-2021, 13:09:26
I would go with Z03.79 and Z53.09. Unless they did the NST due to the elevated BP and her obesity, I would not add those codes. You need more information from the provider.
Posted By Maria on 02-10-2021, 06:54:07
As always, thanks so much for your help!
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