How to Use Indications & Findings in Sonio

In this article:

Indications - Reason for Visit
Findings - Result of Visit
Key Differences at a Glance
Coding Indications & Findings
Coding Guidelines

Indications 

This is the reason for the visit or procedure. It represents the patient's symptoms, signs, or a suspected condition that prompted the healthcare provider to order a test or examination (e.g., Advanced Maternal Age, Gestational Diabetes).

To find the code that reflects the reason for the visit start typing in the search bar. A list of ICD-10 codes will appear and you can select the right one. Sonio automatically filters ICD-10 codes based on the fetal trimester.

During your patient's next exam, Sonio will automatically suggest the codes assigned during the prior visit.

Findings 

Found towards the bottom of the report, Findings are the result or outcome of the diagnostic test or examination. It represents a confirmed diagnosis or an abnormal clinical discovery made after the procedure (e.g., finding a cleft palate on an OB ultrasound).

Key Differences at a Glance

Applying Indication and Findings ICD-10 Dx Codes to Exam, if applicable

In the Coding section at the bottom of the report, you will find the suggested codes that relate to the documented Indications and Findings under Diagnoses.

To apply the suggested codes to the report, click the Sync with Report button.

Depending on practice preferences, the applied ICD-10 Dx codes will be automatically transferred to your EHR or appear at the bottom of the report. Some practices do not have Coding enabled, so this section will be empty. 

Coding Guidelines

• Established Diagnosis: If a definitive diagnosis is made based on the findings, you must code that diagnosis instead of the signs and symptoms (indications).
• Uncertain Diagnosis: In outpatient settings, "probable" or "suspected" conditions cannot be coded. Instead, you should code the indication (the symptom that prompted the visit).
• Abnormal Findings: If a test result is abnormal but does not yet lead to a definitive diagnosis, specific codes for Abnormal Findings are used.

1. Primary Diagnosis (Principal)

The primary code is the main reason for the patient's encounter. In obstetrics, codes from Chapter 15 (O00–O9A) almost always take sequencing priority over codes from any other chapter.

• Normal Pregnancy: For a routine visit with no complications, a code from category Z34 (Supervision of normal pregnancy) is the primary diagnosis.

• High-Risk Pregnancy: For a routine visit where the patient is high-risk, a code from category O09 (Supervision of high-risk pregnancy) is the primary diagnosis.

• Complications: If a patient is admitted for a specific complication (like preeclampsia or preterm labor), that complication code is the primary diagnosis.

• Delivery: If a delivery occurs, the code for the condition that necessitated the delivery (e.g., a C-section due to fetal distress) is sequenced first.

   

2. Secondary Diagnosis (Additional)

Secondary codes provide extra detail about the patient's health during the pregnancy but aren't the main reason for the visit. Definitive Healthcare

• Underlying Conditions: If a patient has a pre-existing condition (like Type 2 Diabetes), you first use a Chapter 15 code (e.g., O24 for diabetes in pregnancy) as primary, followed by the specific diabetes code (E11) as a secondary diagnosis to show the exact type.

• Gestational Age: A code from category Z3A (Weeks of gestation) is always a secondary code and should be included on every maternal record to identify how far along the pregnancy is.

• Outcome of Delivery: For delivery encounters, code Z37 (Outcome of delivery, e.g., single live birth) is used as a secondary code.

• Lifestyle Factors: Codes for tobacco or alcohol use are added as secondary diagnoses when they complicate the pregnancy.

   

Summary Table