Question: A patient had a C-section following a failed VBAC due to fetal distress. She had vaginal bleeding; the OB-GYN performed a hysterectomy during the C-section. How should we best communicate the diagnosis information for this encounter?
Answer: There are potentially multiple pieces of diagnosis information that would be helpful for the anesthesia biller/coder, including:
- Encounter for full-term uncomplicated delivery (O80)
- Maternal care for low transverse scar from previous cesarean delivery (211)
- Labor and delivery complicated by fetal stress, unspecified (O77.9)
Ultimately, the best diagnosis information to provide us is whatever reasons exist for an unsuccessful VBAC—just describe/document why it was unsuccessful.
Also, presuming an epidural catheter was placed for the VBAC, the delivery itself can be reported with 01967 (Neuraxial labor analgesia/anesthesia for planned vaginal delivery [this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor]) and +01969 (Anesthesia for cesarean hysterectomy following neuraxial labor analgesia/anesthesia.)