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help with dx code

Vangie Posted Wed 18th of May, 2011 16:47:04 PM

Patient came to outpatient OB gyn Clinic. Transvaginal was done. Complete placenta previa noted. Cervical length was measured and noted between 50 mm to 48.1 mm. Findings discussed with patient. Patient has history of gestational diabetes in previous pregnancy and she is 37 multigravida. Check one hour glucola.

assessment:

1. Complete placenta previa.
2. H/O Cervical incompetence 50 mm to 48.1. Will place cerclage at 15 weeks.

641.03 Placenta previa
???? H/O cervical incompetence (what code do I use)
654.53 or V89.05 ??
V23.89 Supervision of high risk pregnancy, h/o of GDM.

SuperCoder Answered Wed 18th of May, 2011 20:36:37 PM

1.Complete Placenta Previa: 641.03-----Correct for Primary Dx.
...
2.H/O cervical incompetence 50 mm to 48.1 : Cervical incompetence is basically a cervix that is too weak to stay closed during a pregnancy, resulting in a premature birth and possibly the loss of the baby, because of the shortened gestational length. This is caused when the cervical os (opening) is greater than 2.5 cm, or the length has shortened to less than 20 mm. But in the above case it is 48.1 ; This is not a case of cervical incompetency. Since the findings ruled out cervical incompetence, so we can code for suspected condition(V89.05)
...
3.Supervision of high risk pregnancy, h/o GDM: I would definitely go for V23.49 NOT V23.89

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