Maternal patient with twin gestations is seen after ultrasound identifies fetus

Maternal patient with twin gestations is seen after

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Maternal patient with twin gestations is seen after ultrasound identifies fetus B to be in breech presentation O32.1XX2 Maternal care for breech presentation, fetus 2 Explanation: The documentation indicates that although there are two fetuses, only one fetus is determined to be in breech presentation. Whether fetus 2 or fetus B is used, the coder can assign the seventh character of 2 to identify the second fetus as the one in breech. 36-year-old admitted in labor with second child at 39 weeks’ gestation, delivered a healthy baby, delivery complicated by tear of fourchette that was repaired O70.0 First degree perineal laceration during delivery Z3A.39 39 weeks gestation of pregnancy Z37.0 Single live birth
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Guidelines and Examples Chapter 15. Pregnancy, Childbirth and the Puerperium ICD-10-CM 2017 Chapter 15. Pregnancy, Childbirth and the Puerperium 464 ICD-10-CM 2017 3) Episodes when no delivery occurs In episodes when no delivery occurs, the principal diagnosis should correspond to the principal complication of the pregnancy which necessitated the encounter. Should more than one complication exist, all of which are treated or monitored, any of the complications codes may be sequenced first. 4) When a delivery occurs When an obstetric patient is admitted and delivers during that admission, the condition that prompted the admission should be sequenced as the principal diagnosis. If multiple conditions prompted the admission, sequence the one most related to the delivery as the principal diagnosis. A code for any complication of the delivery should be assigned as an additional diagnosis. In cases of cesarean delivery, if the patient was admitted with a condition that resulted in the performance of a cesarean procedure, that condition should be selected as the principal diagnosis. If the reason for the admission was unrelated to the condition resulting in the cesarean delivery, the condition related to the reason for the admission should be selected as the principal diagnosis. 5) Outcome of delivery A code from category Z37, Outcome of delivery, should be included on every maternal record when a delivery has occurred. These codes are not to be used on subsequent records or on the newborn record. c. Pre-existing conditions versus conditions due to the pregnancy Certain categories in Chapter 15 distinguish between conditions of the mother that existed prior to pregnancy (pre-existing) and those that are a direct result of pregnancy. When assigning codes from Chapter 15, it is important to assess if a condition was pre-existing prior to pregnancy or developed during or due to the pregnancy in order to assign the correct code. Categories that do not distinguish between pre-existing and pregnancy-related conditions may be used for either. It is acceptable to use codes specifically for the puerperium with codes complicating pregnancy and childbirth if a condition arises postpartum during the delivery encounter.
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