Question

This is a 33-year-old female, primigravida, who came in experiencing early labor. Patient is at 40 weeks gestation. The patient had been scheduled for a cesarean section due to breech presentation.

This patient has had no significant problems during first, second, or third trimester. The patient’s past medical history is noncontributory. The patient’s LMP was 06/22/2017, placing her EDC at 04/05/2018. Ultrasounds were performed throughout the pregnancy and revealed adequate growth during the pregnancy and EDC remained technically the same.

The patient’s initial blood work showed blood type to be A positive, VDRL was nonreactive, rubella titer indicated immunity, hepatitis B surface antigen (HbsAg) was negative, HIV screen was negative, GC and Chlamydia cultures were negative. Pap smear was normal. Her 1-hour glucose tolerance test was within normal parameters. The patient’s blood count also remained well within normal parameters. Her quad screen for maternal serum alpha-fetoprotein (MSAFP) was normal. Strep culture was likewise negative at 34–35 weeks.

The patient, upon admission, was having contractions approximately every 4–5 minutes, moderate in intensity. The patient had no dilation; presenting part was still in a breech presentation, per bedside ultrasound; and the patient was therefore made ready for primary cesarean section.

The patient was taken to surgery, where primary classical cesarean section was performed with delivery of a breech infant from left sacral anterior positioning, male weighing 6 pounds 10 ounces with Apgars 8 and 8 at 1 and 5 minutes. Placenta delivered intact. Membranes were removed. The patient tolerated the procedure quite well. Estimated blood loss was less than 600 mL.

The patient has had an uneventful postoperative period. She is ambulating well and moving well at this time. The patient is passing gas, moving her bowels, and urinating well; moderate lochia is present; uterus is firm. The patient is discharged from the hospital, being given careful instructions to avoid douching, intercourse, strenuous activity, going up and down stairs, and traveling by car. She is to keep her incision clean with peroxide. She was discharged with Darvocet-N 100 as needed for pain. She will be followed up in 1 week for staple removal. The patient was given information and instructions. Should she experience unusual bleeding; difficulty urinating, voiding, or having a bowel movement; or temperature elevation, she is to contact this physician. The patient’s baby is showing some jaundice and may be kept for another 24–48 hours to evaluate bilirubin levels.

Be sure to list the codes, one code per box, in the correct order, from top to bottom. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices.

Answer 1

CODING

IDENTIFICATION DATA	33 yrs, primi gravida, 40 weeks gestation, Cesarean section,LMP- 06/22/2017 EDC- 04/05/2018
HISTORY	No relevant history of past medical illness, Antenatal period - uneventful
LAB INVESTIGATIONS	Blood counts - Normal Blood group & Rh factor - A'+' VDRL - Non reactive Rubella titer - immunity '++' HBsAg - negative HIV screen - negative GC &Chlamydia culture - negative Maternal AFP - Normal Strep culture - negative
ADMISSION HISTORY	Contractions 4-5 minutes Intensity - moderate Dilatation - Nil Presenting part per USG - Breech
INTRA NATAL &POST NATAL PERIOD	Surgery - Primary Classical Cesarean Section Placenta Delivered intact, membranes removed completely Estimated blood loss - 600ml Post operative period was uneventful
BABY	Gender- Male Weight- 8 pound 10 ounces Apgar score - 8 & 8 at 1 and 5 min respectively

PATIENT DETAILS ON DISCHARGE	Bowel & bladder pattern- Normal Lochia - rubra present Uterus - well contracted
DISCHARGE ADVICE	Health education Follow up - 1 week for staple removal Baby - showing jaundice should be kept for another 24-48 hrs for evaluating bilirubin