ICD-10 Eclampsia Vignette

Eclampsia Vignette Pic

The EMS radio suddenly crackles to life, with sirens in the background. Dr. Green gives her full attention to the report: “We’re coming in code 3 with a level I medical.  We have a 38-year-old female, gravida 3, para-2, at 32 weeks EGA based on recent ultrasound.  She called us for gradual onset headache and ankle swelling.  She just started seizing.  BP 168/105, pulse 110.  We’re assisting ventilation and attempting IV access. We’ll be at your back door in 2-minutes.”

 

The patient is still seizing upon arrival. Dr. Green immediately administers 2 grams of magnesium sulfate through the newly established IV line, followed by 5mg of diazepam.  The seizure stops. Dr. Green completes her assessment. The patient is postictal, disoriented, but moving all extremities and breathing spontaneously.  She has 3+ pitting edema to both calves.  She has RUQ tenderness without peritoneal signs. Her uterine fundus is 12cm above the umbilicus. Urinalysis shows 3+ proteinuria. Her blood pressure improves to 138/92 with 20mg of labetalol IV. Her obstetrician arrives 30-minutes later and admits the patient to the L&D operating room for an emergent C-section.

Dr. Green has carefully documented her findings.

The following ICD-10-CM codes would be assigned to this encounter:

O15.03

Eclampsia in pregnancy, third trimester

Z3A.32

32 weeks gestation of pregnancy

Note:  In ICD-10-CM, most codes related to pregnancy require documentation of trimester and weeks of gestation.

 

For the Evaluation & Management service, the coder would also assign a CPT code such as 99285 or 99291.

 

For additional information on ICD-10 coding for emergency medicine, visit the ACEP Reimbursement page at https://www.acep.org/content.aspx?id=28754.

08/2015

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