Encounter for antenatal screening for uncertain dates
ICD-10 Z36.87 is a billable code used to indicate a diagnosis of encounter for antenatal screening for uncertain dates.
Z36.87 is used to indicate an encounter for antenatal screening when the gestational age is uncertain. This situation often arises in cases where the patient may not have a clear recollection of their last menstrual period or when there are discrepancies in ultrasound dating. The clinical context for this code includes the need for accurate gestational age determination to ensure appropriate prenatal care and interventions. Social determinants of health, such as access to healthcare, education level, and socioeconomic status, can influence a patient's ability to provide accurate dating information. Preventive care is critical during this stage, as it allows for timely screenings and interventions that can significantly impact maternal and fetal health outcomes. Screening for conditions such as gestational diabetes and preeclampsia is essential, and accurate dating is crucial for these assessments. Aftercare may involve follow-up appointments to monitor the pregnancy's progress and address any complications that arise due to the uncertainty in dating.
Documentation should include the patient's menstrual history, any ultrasounds performed, and the rationale for the uncertain dates. Preventive measures taken during the encounter should also be documented.
Routine checkups where the patient reports uncertain dates, screenings for gestational diabetes, and follow-up visits to monitor pregnancy progress.
Consideration of social determinants such as access to healthcare services, education level, and support systems that may affect the patient's ability to provide accurate information.
Documentation should focus on population-level data, including tracking of uncertain dating cases and their outcomes. Surveillance data may also be collected.
Epidemiological studies assessing the impact of uncertain dating on maternal and fetal health outcomes.
Reporting on health disparities related to uncertain dating and access to prenatal care.
Used during a routine prenatal visit where uncertain dates are discussed.
Documentation must include the patient's history, any examinations performed, and the rationale for uncertain dating.
Primary care providers should ensure comprehensive documentation to support the use of Z36.87.
Z36.87 should be used when a patient presents for antenatal screening and the gestational age is uncertain. It is important to document the reasons for uncertainty and any follow-up actions taken.
