Conditions of Pregnancy, Childbirth, and the Puerpera june 20-yesdy female has had two spontaneous abortions because of incorgy While Because of mis the had a cervical cerclage placed in the third month with 4 running and locking fashion.

Conditions of Pregnancy, Childbirth, and the Puerpera june 20-yesdy female has had two spontaneous abortions because of incorgy While Because of mis the had a cervical cerclage placed in the third month with 4 running and locking fashion. A second layer of No. 1 chromic suture was Pel thesharsey She is coming in now to have the cerclage removed under general IN " Lembert fashion to imbricale the first layer, craming a double leryer closure. uterine incision was inspected and hemostasis conferred. es. She was taken to surgery and the cerclage was removed without corptalk Has discharged thet evening. There are no signs of labor, and the more yo She was instructed on the signs of labor and will see me in the office file The uterus was returned to the abdominal cavity. The ularme incision was insports The again for hemostasis. All blood and clots were clearns from the lateral gutters Mys. Gestational age is 38 weeks and labor is expected to begin any time. Pen a final inspection soferings hemostasis of the uterine Ficision, The restus muscles that are the correct ICD-10-CM and CPT code assignments for this case? Where brought together will three simple interrupted 2-0 Vitry sutures, Hemostasis Will Menformed at the level of the rectus muscles and then the fascia was reapproximate (34.33 234 36 (The cerclage removal is part of the global package.) Using two separate Civicryl sutures in a running fashion. The subcutaneous tissues 4 034.33. 834 38. 50871 were irrigated and the skin was reapproximated with surgical sisel staples. A where dressing was applied. The patient was laken to the recovery room in stable and N58.3. with appropriate EM procedure satisfactory condition having tolerated the procedure well. N88 3. 59871 The folowing documentation is from the health record of a 24-year-old female pal, what is the correct CPT code assignment for this service? The obstetrician who CPT code(s): performed the cesarean section also provided antegarturn and postpartum care. 2. Polyhydramnios 1 . Term intrauterine pregnancy at 39 3/7 weeks Preoperative Diagnoses: 3. Failure to progress 495. This 26-year-old 51P1 female al 12 weeks gestation, has been spotting and on bea 1. Term intrauterine pregnancy at 39 3/7 weeks west. She awoke this moming with severe cramping and bleeding and her husband Postoperative Diagnoses: 2. Viable male infant. Apgars: 8/9 at one and to brought her to the hospital. After examination, it was determined that she has had an incomplete early spontaneous abortion. She was taken to surgery, and a dilation and minutes respectively. Birth weight 7 pounds curetage was performed. There were no complications from the procedure. She is to ounces follow up with me in the office. She has had four anlepartum visits during her pregnancy Primary cesarean section with low-transit What is the correct ICD-10-CM and CPT code assignment? 003.9, Z3A. 12, 59812 uterine incision 003.4, Z3A. 12, 59812, 59425 Operation: 003.4, Z3A. 12. 58120 Spinal 003.9, Z3A.12, 58120, 59425 Anesthesia: 500 cc Estimated Blood Loss: 6.98. Procedure: McDonald’s corolage placement None Complications: Postoperative Diagnosis: Intrauterine pregnancy at 14 weeks: patient has a history of cervical incompetence Description of Procedure: The patient was brought to the surgical delivery tox Anesthesia: Epidural Suite and anesthesia was administered. The patient was placed in a supine posts With left lateral uterine displacement. The abdomen was sterilely prepped and arap History: The patient is a 31-year-old gravida 4, para 2, A positive HCG was noted in the normal fashion for cesarean section. approximately six weeks ago, Ultrasound reveals an intrauterine pregnancy in the second After ascertaining the adequacy of the anesthetic level with an Allis test, a Planners semester. Her previous pregnancies were brought to term using cerclage. Incision was made approximately three finger breaths above the pubic symphysis ap Findings: Preoperatively the internal os was approximately 1,2 cm dilated. The posterior camled down to the level of the fascia. The fascia was dissected off in the micky cervix was approximately 2 cm long and the interior cervix was approximately 1.1 cm long- and the peritoneum was carefully entered. The bladder was retracted inferiorly wit DeLee retractor and then a bladder flap was created. The DeLee retractor wiz The patient was placed in the dorsal lithotomy position and prepped and draped for cerclage. A Mersilene band was used with one needle placed in at the 6 o’clock position repositioned to further retract the bladder inferiorly. and brought out at the 3 o’clock position and replaced at the same position and brought A transverse curvilinear incision was made in the lower uterine segment and extends out at the 12 o’clock position. A second needle was taken in at 3 o’clock and brought upward and laterally using blunt dissection. Fetal membranes were ruptured and: out at 9 o’clock and then replaced and brought out in the 12 o’clock position. viable male infant was delivered from a vertex presentation in an atraumatic fast ix The Mersilene band was then tied at the 12 o’clock position and the internal os was The oropharynx and nares were suctioned on the operative field. The umbilical cord as closed. At the end of the procedure the knot could be felt at the appropriate position doubly clamped and cut. The infant was handed off to the awaiting pediatric persone and the internal os was closed to digital examination. Cord blood was obtained after a segment of cord was clamped and saved for coy The procedure was without complications, and the patient was taken to the PACU in blood gases pending Apgars. The placenta was delivered by manual extraction. The good condition. uterus was explored to remove any remaining fragments of membranes. The uleu was exteriorized. The uterine incision was reapproximated using No. 1 chromic sutax What codes are used to report this outpatient encounter? ICD-10-CM and CPT Code(s): 159

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