A 19-year-old girl had been diagnosed as having SLE 15 months ago, following presentation with an arthritis in her hands, a rash (livido reticularis) on her arms and considerable spontaneous

PATIENT: LONGENSTEIN, GERI
ACCOUNT/EHR #: L018-038546321
Attending Physician: Yancy Morrison, MD

Admission Date: 03/15/18
Discharge Date: 03/17/18

LABOR & DELIVERY REPORT:

A 19-year-old girl had been diagnosed as having SLE 15 months ago, following presentation with an arthritis in her hands, a rash (livido reticularis) on her arms and considerable spontaneous bruising.
She had had antinuclear antibodies of 1/320, C3 of 450 mg/l, C4 of 70 mg/l and a platelet count of 54 ×109/l at that time. Renal function was normal but she had both low titre antiphospholipid antibodies and a lupus anticoagulant, though no antibodies to double stranded DNA (ds DNA), at presentation. Further results of the blood tests were noted as the patient is suffering from thrombocytopenia. Due to her pregnant condition this of concern.
She consulted an obstetrician at 16 weeks into an unexpected pregnancy whilst in disease remission and on 5 mg of prednisolone daily; she had taken the message about possible difficulties with achieving a family too literally! She was seen every 2 weeks throughout the pregnancy to monitor her disease activity; regular full blood counts, C3, C4, creatinine, anticardiolipin and ds DNA antibody measurements were done as well as urine and blood pressure monitoring.

These tests were unchanged throughout the pregnancy.

Today, a single, live, normal, male infant was delivered by classical Caesarean section at 38 weeks in view of the low platelet count
I need help finding the codes
You’re looking for:
Five diagnosis codes
Google “SLE medical abbreviation” if you don’t know what that is.
Connect wants D69.3 in the second diagnosis slot, but there’s not enough documentation for it. It might be in the interpretation of the lab values, but we need the physician to say something about it before we can code it. Without the D69.3, we get an edit in 3M that tells us we have to have a code for a blood and/or blood forming organ disease to go with the O99.12 complication code. We can’t just add a NOS code if they don’t say anything about it. This would be a good case to query the physician on the job.
Be sure to look at the Coding Clinics on the 3M end screen.
One ICD-10-CM procedure
We’ll call this a classical procedure.