Maternal labor and delivery note-What is the procedure

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Reference no: EM133877119

CASE 1 (Process 1: CPT)

Maternal labor and delivery note: Patient is a 38-year-old female with estimated date of conception 10/09 and estimated gestational age of +41 weeks. Her prolonged labor began with uterine contractions for the past 2 days, mild this a.m. and increasingly more severe this evening, with contractions now every 2 to 4 minutes. Cervix is 1 cm/20 percent/=1 station, EFW3, 500 g, 7/21. Patient did progress to 7 cm; however, she was exhausted due to labor and loss of sleep for the past 2 nights due to her labor pain.

Delivery of a single viable female infant was performed vaginally with vacuum assistance. Episiotomy with fourth-degree laceration was repaired with 2-0 and 3-0 Vicryl.

Process 1: CPT

What is the procedure?

Locate the main term in the index.

What additional questions or set of questions can be determined?

Based on the documentation, what is the correct code for this case?

Process 2: ICD-10-CM

Based on the operative report header, what is the preoperative diagnosis?

Is the postoperative diagnosis the same as or different from the preoperative diagnosis?

Is the postoperative diagnosis supported?

What is the main term for this condition?

Based on the subterm choices, what question(s) can be developed for this condition?

Based on the information in the Tabular List, is additional information needed to determine the appropriate diagnosis code?

Is any sign, symptom, or additional condition documented?

Based on the documentation, what is the correct ICD-10-CM code for this case?

Process 3: Modifiers

Was the procedure performed different from that described by the nomenclature of the code?

Was the procedure performed at an anatomical site that has laterality?

Was the procedure performed in the global period of another procedure?

Were additional procedures performed during the operative session, and does the documentation support them?

Did the surgeon have help from another surgeon or another appropriate person?

Did a physician different from the surgeon provide the preoperative or postoperative portion of the procedure?

What modifier(s) should be appended to the CPT code for this case?

Reference no: EM133877119

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