Q&A Priciple diagnosis in a delivery

[Jack Kline]

Is there a hierarchy or rule to determining the PDx for a complicated delivery?

 

[Jack Kline]

By complicated I mean she is having twins and starts contractions at 34 weeks and mild pre-eclampsia. Thanks, Jack

 

[Alicia Scott]

Yes there is. With just the information you have given me I would code it like this:
V23.89 Supervision of Other High-Risk Pregnancy
651.03 Twin Pregnancy
644.03 Threatened Premature Labor after 22 wk, before 37 wks
642.43 Mild Pre-Eclampsia

So, Why is she being seen? Supervision preterm labor, pre-clampsia and she has twins.
Always note multiple gestations!
What is happening? Contractions-preterm
Any other complications? Swollen and blood pressure is high. She most likely has protein in her urine. These are signs of pre-eclampsia. This does not cause contractions so is an additional complication.

 

[Jack Kline]

This is a scenario I made and should of been more specific. She delivered on this IP visit. Seems like Twins get principle Dx and premature labor gets secondary.

Read Faye Brown and Chapter 11 guidelines helped too.

Thanks for your reply, Jack

 

[Alicia Scott]

Yes, that changes things.