Documentation Dissection - AAPC

1 1 Documentation DissectionHPI: 39 y/o G5P2 LMP 4/17 presents with vaginal bleeding. She has had miscarriage x :39 y/o G5P2 at approximately 6 wk per LMP |1| presents with vaginal Threatened miscarriage in early pregnancy |2|2. UTI |3|_____|1| Patient is 6 weeks pregnant placing her in the first trimester.|2| Primary diagnosis to report. Vaginal bleeding is a sign/symptom of the threatened miscarriage and is not reported.|3| Additional complication of the ICD-10-CM code(s) is/are reported?ICD-10-CM Codes: , , : The patient had a threatened miscarriage.

2 Look in the ICD-10-CM Alphabetic Index for Threatened/miscarriage Next, look in the Alphabetic Index for Pregnancy/complicated by/infection/urinary (tract) In the Tabular List, fifth character 1 is reported for the first trimester. There is a note at category O23 to identify the organism with an additional code. The organism is unknown so this is not reported. There is a note at the beginning of ICD-10-CM Chapter 15 to also report the weeks of gestation. Look in the ICD-10-CM Alphabetic Index for Pregnancy/weeks of gestation/less than 8 weeks