[Gnumed-devel] How within GNUmed to use coding e.g. capturing the fact and state of current pregnancies (?)

[Jim Busser]

I am starting to think more how to use coding in GNUmed, from the point of view 
of queries that will help in providing more-enlightened, evidence-based care.

Whichever way a particular pregnancy is entered (as an episode or as an issue) 
it is desirable to be able to reliably determine, within a GNUmed praxis, who 
is pregnant at any one time. Use cases include programs of vaccination where 
pregnant women have been identified to be at special risk. Another use case 
would be where it is newly identified that drug X confers previously 
unrecognized dangers to the fetus.

In GNUmed, one could create a health issue

        Pregnancies

where each of a series of gestations could be their own (rather long) episode. 
Alternatively, each could be their own health issue wherein stages could each 
be episodes…

        … pre-conception
        … conception confirmation / first trimester
        … second trimester
        … third trimester
        … labor and delivery
        … puerperium

Clinical problems which warrant separate status and tracking (Rh negative 
patient, Rh positive father) likely warrant to be their own issue, even if they 
would be identified within (in the course of) a pregnancy.

My question is how 'pregnancy state' would best be tracked?

ICD-9-CM and ICD-10-CM divide their codes based on whether a diagnosis or 
problem was:

- a reason for the visit
        (codes beginning with letters A through Y)

- vs whether a condition affecting health status was incidental
        (codes beginning Z)

and also divides pregnancies into normal and high risk:

        
http://health-information.advanceweb.com/Article/Review-Obstetric-Newborn-Coding-Guidelines.aspx
        
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_022421.hcsp?dDocName=bok1_022421
        
http://en.wikipedia.org/wiki/List_of_ICD-9_codes_630–679:_complications_of_pregnancy,_childbirth,_and_the_puerperium

but what the patient *claims* to be (and what the doctor records to be) the 
reason for the visit is sometimes affected by what will net the patient the 
lowest out-of-pocket charges, on account of some care being 'covered' and other 
care 'not'. Even if the entries were to be made 'consistently' there is a 
problem in that the same biological state is being entered under two different 
codes within the same coding system. Ugh!

Interesting from

        https://www.cms.gov/ICD10/Downloads/7_Guidelines10cm2010.pdf

Page 96: Do not code diagnoses documented as “probable”, “suspected,” 
“questionable,” “rule out,” or “working diagnosis” or other similar terms 
indicating uncertainty. Rather, code the condition(s) to the highest degree of 
certainty for that encounter/visit, such as symptoms, signs, abnormal test 
results, or other reason for the visit. Please note: This differs from the 
coding practices used by short-term, acute care, long-term care and psychiatric 
hospitals.

Page 97: Chronic diseases treated on an ongoing basis may be coded and reported 
as many times as the patient receives treatment and care for the condition(s). 
Code all documented conditions that coexist at the time of the encounter/visit, 
and require or affect patient care treatment or management. Do not code 
conditions that were previously treated and no longer exist. However, history 
codes (categories Z80- Z87) may be used as secondary codes if the historical 
condition or family history has an impact on current care or influences 
treatment.

Does there exist any 'best way forward' ?

-- Jim