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April 03, 2014

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Code This!

Current Scenario Week of April 03, 2014:
View Answer From Last Scenario

Assign the correct codes for the following inpatient scenario using ICD-9-CM diagnosis and procedure codes and ICD-10-CM and ICD-10-PCS codes:

HISTORY: This 23-year-old patient received uncomplicated prenatal care in my office, with the exception of mild hemorrhoids, until yesterday when she noted decreased fetal movement. She presented today to the hospital for evaluation and no fetal cardiac activity was noted. This was confirmed with ultrasound. The patient was admitted with a diagnosis of intrauterine fetal demise at 36 weeks' gestation.

SUMMARY: The patient was 3 cm dilated on admission. IV Pitocin was started for induction of labor, with epidural placed for labor pain. She did develop a temperature of 100.4 and antibiotics were ordered. She remained febrile, approximately 100.1. Her labor progressed well and she completely dilated, pushed approximately three times, and proceeded with delivery.

She was transferred to postpartum for uneventful recovery, continued on gentamicin and clindamycin secondary to fever. She was discharged home the following morning afebrile. She should increase her fiber content in the diet, use stool softeners, increase liquid intake, and use anti-hemorrhoidal analgesics for her mild external hemorrhoids.

FINAL DIAGNOSIS: Intrauterine fetal demise at 36 weeks' gestation
Second-degree midline laceration
Tight nuchal cord x1
Fever during labor
External hemorrhoids

DELIVERY NOTE: Preterm induced spontaneous vaginal delivery of an intrauterine fetal demise. Fetal position is right occiput anterior.

COMPLICATIONS: Intrauterine fetal demise — male infant, grossly morphologically normal. Apgars were 0 and 0. 18.66 inches / 47.4 cm; 5.78 pounds / 2622 grams.

Tight nuchal cord x1. Small second-degree midline laceration. Fever during labor.

NARRATIVE OF DELIVERY: I was called and arrived in the delivery room when the patient was fully dilated. She pushed for three contractions and then delivered the fetal vertex in the right occiput anterior position followed by the remainder of the infant. There was a tight nuchal cord x 1 that was reduced after delivery. The cord was doubly clamped. The placenta delivered spontaneously and was carefully examined and found to be intact, without signs of abruption or abnormal cord insertion. The cord was examined and three-vessel cord was confirmed. The vagina and perineum were carefully inspected. A small second-degree midline laceration was repaired in a normal running fashion with a 3-0 Vicryl suture. Estimated blood loss was 100 ml.

Please assign the correct ICD-9-CM and ICD-10-CM/PCS codes for the procedure above.

 

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