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November 23, 2022

A 33-year-old female who received hospital observation services.

The following documentation is from the health record of a 33-year-old female who received hospital observation services. Observation Patient Admit Note: 2/28/XX, 07:30 This is a 33-year-old G2, PO, estimated delivery date of 2/28 and estimated gestational age of 40 weeks. She presents for induction secondary to gestational diabetes mellitus. She has required insulin since 28 weeks with adequate control. PNL: O positive, rubella immune. PE: AVSS, abdomen FH 40 cm, EFW 3800-4000 g. Cervix is closed/50 percent/-3/post/ ceph. Plan is for Prostin EZ induction and insulin infusion when in active labor. Progress Note: 2/28/XX, 09:15 Patient is having uterine contractions every three to eight minutes. Cervix is 1 cm/100 percent/floating. Patient does not want to start Pitocin yet. Feels that she is in labor. FHR reactive, baseline 120s with accelerations. Progress Note: 2/28/XX, 19:25 Patient’s uterine contractions have resolved. Cervix unchanged. Discussed options, would like to go home to sleep and return in a.m. for Pitocin induction. Discharged home for tonight to sleep. Admit in a.m., start IV Pitocin as per protocol, start insulin drip, clear liquid diet. Which of the following is the correct ICD-10-CM code set for this outpatient encounter?

a. 024.424, Z3A.40 b. 024.414, E11.9, Z3A.40 C. 024.414, Z3A.40 d. 024.414, R73.9, Z3A.40

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