Abstract from Documentation: Refer to Amniocentesis in the Alphabetic Index. What documentation is needed to select the applicable code range? Underline the portion of the operative report that supports your answer.
Procedure Performed: Amniocentesis
Reason for Procedure: The patient is a 30-year-old white female who is gravida 7, para 1, with intrauterine pregnancy at 36-4/7 weeks gestation. She was admitted in prodromal labor. She has gestational diabetes mellitus and an ultrasound suggesting fetal weight of greater than 10 pounds. The patient has been quite uncomfortable in recent weeks and is adamant about wanting to be delivered. In view of the gestational diabetes requiring insulin, I feel it important to document fetal lung maturity in a more or less elective delivery.
I discussed amniocentesis and the risks, benefits, and alternatives. After I answered her questions, she agreed to proceed with the procedure.
Description of the Procedure: Under ultrasound guidance a 4 to 5 cm pocket of amniotic fluid was identified in the fundal left side. The abdomen was prepped and draped. Under ultrasound guidance a 22-gauge needle was inserted into this pocket and approximately 8 cc of fluid was obtained, which was lightly bloodstained. I attempted to aspirate more using a second syringe but was unable to get further fluid so the procedure was terminated.
Assessment and Plan: Post procedure the fetal heart tracing was obtained and fetal heartbeat was in the 150s. Biophysical profile post procedure was 10 out of 10. We will await the amniocentesis results and if the l/s (lecithin/sphingomyelin) is mature, we will proceed with cesarean section.
The documentation needs to support the reason for the procedure: diagnostic, therapeutic, or for an abortion.
CPT Code Assignment:
59000 Amniocentesis; diagnostic
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