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Incidental vs. Complicating?

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Situation:

Cathie Wilde, RHIA, CCS, Vice President of Coding Services

Cathie Wilde, RHIA, CCS, Vice President of Coding Services

A 21 year old female is admitted to the hospital with abdominal pain. Testing reveals patient with pelvic inflammatory disease (PID), bacterial vaginosis and a positive pregnancy test. History reveals the patient was sexually assaulted 3 weeks prior and PID likely related to that incident. The patient plans to terminate the pregnancy at Planned Parenthood following discharge and does not want her family to know.

This patient’s discharge diagnoses are:

PID

Bacterial vaginosis

Pregnancy

Should this be coded to pregnancy complication or incidental pregnancy (V22.2) (or even positive pregnancy test – V72.42)?

Here are my thoughts…

According to Coding Clinic guidelines, it is the provider’s responsibility to state that the condition being treated is not affecting the pregnancy.[1] Despite the fact that the patient is early in the pregnancy, the physician did not state specifically that the PID was not affecting her pregnant state. As such, the patient’s admission would be coded to:

646.63

614.9

616.10

Even in circumstances involving a seemingly unrelated diagnosis such as a toe fracture from patient stubbing her foot would be required to be assigned to a pregnancy complication unless the physician has specifically documented that the pregnancy is NOT affected. Considerations of how the fracture might be affecting the pregnant state is difference in treatment plan rendered because of pregnancy such as not doing an x-ray or prescribing a different medication that they might not otherwise use.

What do you think?

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