Question

Indications: 31 y/o G3P1 at 39 and 4/7 weeks admitted in labor. She has been followed in the OB clinic with 12 normal antenatal visits. Stage I: Patient was admitted with a cervical exam of 3/c/-1. She slowly progressed to 5 cm dilation. She had SROM at 0330 which showed light meconium. She continued to labor and reached the end of stage I at 1000, a period of 10 hours. FHTs showed some periods of reactivity but responded to stimulation. Stage II: Duration of Stage II (from pushing to delivery) was approximately 3 hours. A pediatric team was present. There was slight meconium staining present at delivery. Presentation was OP with right shoulder anterior shoulder. There was no nuchal cord. The cord was clamped x2 and cut and the baby was handed to pediatric team. Gender: Male Weight: 3772 grams. Apgars 8 /9 Stage III: Placenta delivered spontaneously with gentle traction and fundal massage and was intact. Vagina and cervix examined for lacerations. Inspection revealed a small second degree perineal laceration which was repaired with 3.0 Polysorb in the usual sterile fashion in layers. Another small lateral cutaneous tear was repaired with 3.0 polysorb and a figure-of-eight stitch. Good hemostatis was noted. Patient will return to clinic for follow-up in 6 weeks. What are the CPT® and ICD-10-CM codes?

Answer 1

This question pertains to medical coding, specifically ICD-10 and CPT codes related to an obstetrical case. The coding for this scenario could be 'O80' for the ICD-10-CM code, '59400' for the routine obstetric care CPT code, '12011' for laceration repair, and 'O68.0' for meconium presence.

Step-by-step explanation:

The particular question pertain to medical coding, specifically ICD-10 and CPT codes related to an obstetrical case. Understanding each detail of the patient’s labor and delivery experience is critical to accurate coding. In this case, for the primary diagnosis and reason for the visit, the ICD-10-CM code could be 'O80' for spontaneous vertex delivery. The procedure, specified as vaginal delivery, is coded in CPT as '59400' for routine obstetric care. Additionally, the repair of a second-degree perineal laceration, CPT code '12011'. The presence of meconium staining, a complication of labor and delivery, would be coded 'O68.0'. Please note that final confirmation and verification with a certified professional coder or the most recent coding books/manuals is highly advisable as codes may change over time.

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