OB/GYN Cesarean Section

Hi

Need help in selecting diagnoses codes for cesarean section. Here are the details.

Procedure: Primary low-transverse cesarean section and tubal ligation (took 59515 & 58611)

Diagnoses: Term intrauterine pregnancy, breech malpresentation, and desires permanent sterilization.

I chose 669.71 & V27.0

My doubt is: should we have to code breech malpresentation and desire for permanent sterilization..

Please help.. i am new to OB/GYN coding..

Thanks in advance

re: OB/GYN Cesarean Section

The breech is your "indication"; if causing obstruction of descent, leading to the c-section: 660.01, 652.21, and V25.2 on the tubal.

re: OB/GYN Cesarean Section

Thanks for your support.

Should i take both 660.01 & 652.21 instead of 669.71?
And, is it necessary to code the outcome of delivery or not?

re: OB/GYN Cesarean Section

Not for the mom.

re: OB/GYN Cesarean Section

The 669.71 should only be used if you have no idea why the c-s was done. You should be able to get the reason from the op note.

re: OB/GYN Cesarean Section

I could get from findings: Male infant in breech presentation, clear fluid, normal tubes, uterus and ovaries.. That's it.
Op note is only on conducting the cesarean section and tubal ligation.

re: OB/GYN Cesarean Section

Then, leave out the obstruction if not documented. Perhaps ask your provider to be more detailed dictating.