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Inpatient coding tip: Understanding OB-GYN Diseases & Procedures

Staff Development Weekly: Insight on Evidence-Based Practice in Education, August 5, 2005

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Coding gynecology and obstetrical services requires great attention to detail and a careful reading of the medical record. The electronic medical record and other documentation advances (e.g., the scanning of forms) provide better sources of information for you to review. Most obstetrical practices pre-send the antepartum data to the facility so a history of some sort is usually available to the delivery team. Notes may be recorded in a less standardized fashion-especially in the obstetrical record-and therefore, may be more difficult to interpret.

Remember to keep the mothers and infants records separate and to record the particular codes in the correct records. As of 2005, ICD-9 and I-9 coding changes are introduced twice a year. Take steps to stay current with all changes as they are announced because once they are implemented there will no longer be a grace period.

Editor's note: The above excerpt is from the new online course, "Inpatient Coding Module: Understanding OB-GYN Diseases & Procedures." For more information on this and other courses in our Coding library, go to www.hcprofessor.com and click on Coding and Reimbursement.

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