Lesson 5 OB and NB
ICD-10-CM Codes O00-O9A Official Guidelines for Coding and Reporting, Section I.C.15 © Kathleen Peterson, MS, RHIA, CCS 1 ICD-10-CM Code ICD-10-CM Code Description Z30.01- Encounter for initial prescription of contraceptives Z30.02 Counseling & instruction in natural family planning to avoid pregnancy Z30.09 Encounter for other general counseling & advice on contraception Z30.4 Encounter for surveillance of contraceptives Z31.- Encounter for procreative management Z32.- Encounter for pregnancy test & childbirth & childcare instruction Z33.1 Pregnant state, incidental • Used in place of chapter 15 codes; provider must state the condition treated is not affecting pregnancy Z34.- Encounter for supervision of normal pregnancy Z3A.- Weeks of gestation Z39.- Encounter for maternal postpartum care & examination © Kathleen Peterson, MS, RHIA, CCS 2 Provider sees a pregnant women at 25 weeks gestation for persistent pain in right ear which has worsened over the last 5 days. The provider determines the patient has acute serous otitis media in right ear; this condition is not related to pregnancy. Antibiotics are prescribed. A 22-year-old primigravida female patient presents for first OB visit. She is approximately 7 weeks pregnant. After examination, patient is prescribed prenatal vitamins and will return in 4 weeks for followup. Pregnancy Incidental Normal Pregnancy © Kathleen Peterson, MS, RHIA, CCS 3 ICD-10-CM coding guideline, Section I.C.15.q Abortion with live fetus ◦ Z33.2 Encounter for elective termination of pregnancy with code from category Z37, Outcome of Delivery ◦ By definition, a live fetus is a fetus having any heartbeat, respiration or involuntary muscle movement after expulsion, no matter how long it survives. Retained products of conception following an abortion ◦ Use appropriate code from category O03, Spontaneous abortion, or codes O07.4, Failed attempted termination of pregnancy without complication and Z33.2, Encounter for elective termination of pregnancy. Complications leading to abortion ◦ Any code from chapter 15 for documented complications of pregnancy may be assigned with codes in categories O07 and O08. © Kathleen Peterson, MS, RHIA, CCS 4 The expulsion or extraction from the uterus of all or part of the products of conception An embryo or a nonviable fetus weighing less than 500 grams Spontaneous – one that occurs without any instrumentation or chemical intervention Treatment: D&C, aspiration D&C, or suction D&C may be performed immediately following abortion if there is a question of incomplete abortion Performing D&C is not evidence of incomplete abortion © Kathleen Peterson, MS, RHIA, CCS 5 Definition: unexpected AB occurs when patient undergoes major trauma or surgery during pregnancy resulting in loss of fetus ◦ Direct inadvertent AB - patient loses fetus, after surgery on uterus for condition unrelated to pregnancy PDX = condition occasioning admission SDX = Z33.2 (to indicate termination of pregnancy occurred) ◦ Indirect inadvertent AB - patient loses fetus, after major trauma or surgery other than on uterus PDX = condition occasioning admission SDX = O03.9 (classify as spontaneous AB) © Kathleen Peterson, MS, RHIA, CCS 6 Missed AB: occurs when the fetus had died before completion of 20 weeks gestation, with retention in the uterus for 4 or more weeks. ◦ Use code O02.1 Missed Intrauterine death: occurs when the fetus had died after completion of 20 weeks gestation, with retention of the dead fetus. ◦ Use code O36.4Missed abortion with blighted ovum, nonhydatidiform mole or hydatidiform mole is assigned to O02.0 or a code from category O01, Hydatidiform mole © Kathleen Peterson, MS, RHIA, CCS 7 O00 Ectopic pregnancy ◦ Abdominal, tubal, ovarian, other O01 Hydatidiform mole ◦ Particular type of molar pregnancy ◦ Molar pregnancy occurs when a blighted ovum within the uterus develops into a mole or benign tumor. O02 Other abnormal product of conception © Kathleen Peterson, MS, RHIA, CCS 8 Assign ICD-10-CM codes for: 1. Incomplete, spontaneous abortion at 9 weeks gestation 2. Ectopic pregnancy, right fallopian tube © Kathleen Peterson, MS, RHIA, CCS 9 Section I.C.15.a OB cases require codes from Chapter 15 Chapter 15 codes have sequencing priorities over codes from other chapters Additional codes from other chapters may also be assigned to specify conditions. Provider must document if the condition being treated does not affect the pregnancy. Chapter 15 codes only used on mother’s record. Final characters indicate the trimester for most chapter 15 codes ◦ Assign based upon provider documentation of the trimester for the admission or encounter ◦ Use “in childbirth” option for codes when delivery occurs during current admission © Kathleen Peterson, MS, RHIA, CCS 10 ICD-10-CM Coding Guidelines, Section I.C.15.b. Circumstances of encounter determine selection of PDX or first-listed diagnosis ◦ Selection of PDX main circumstances or complication of delivery If C-section, PDX is condition after study responsible for patient’s admission When C-section is performed, the condition responsible for patient’s admission may or may not be the same as the reason for the Csection Routine outpatient prenatal visits → Z34.- may not use with any OB complication code. Routine outpatient prenatal visits for high-risk pregnancies → category O09 as first listed diagnosis; followed by chapter 15 codes. OB episodes without delivery → code principal complication of pregnancy resulting in encounter. © Kathleen Peterson, MS, RHIA, CCS 11 Look under the following main terms ◦ ◦ ◦ ◦ ◦ Pregnancy Delivery Puerperal, Puerperium Specific complication Outcome of delivery (Category Z37, only on delivery record only) In the encoder, search the main term, complicated by, disorder e.g., Pregnancy e.g., mental disorder © Kathleen Peterson, MS, RHIA, CCS 12 Only assign to maternal record Indicates weeks of gestation of the pregnancy Look at the prenatal record to find information Z3A.01 – Z3A.42 ◦ Less than 8 weeks – greater than 42 weeks ◦ Z3A.00 Weeks of gestation, not specified - Rarely used © Kathleen Peterson, MS, RHIA, CCS 13 Antepartum = Prenatal Period: from time of conception to beginning of regular uterine contractions Labor and Delivery Postpartum = Puerperium: begins with end of the 3rd stage of labor and continues for 6 weeks © Kathleen Peterson, MS, RHIA, CCS 14 Preterm ◦ delivery before 37 completed weeks of gestation Term ◦ delivery between 38 and 42 weeks of gestation Post-term ◦ delivery after 42 weeks of gestation © Kathleen Peterson, MS, RHIA, CCS 15 See instructional note at beginning of chapter 15 1st trimester: less than 14 weeks 0 days 2nd trimester: 14 weeks 0 days to less than 28 weeks 0 days 3rd trimester: 28 weeks 0 days until delivery © Kathleen Peterson, MS, RHIA, CCS 16 Official Guidelines for Coding & Reporting, Section I.C.15.n What does it mean? Minimal or no assistance With or without episiotomy Without fetal manipulation (fetal presentation is occipital or cephalic) Antepartum conditions resolved prior to admission for delivery Single, full-term infant Vaginal delivery ◦ Episiotomy without forceps ◦ Episiorrhaphy ◦ Amniotomy (AROM) ◦ Manually assisted delivery without forceps ◦ Administration of analgesia &/or anesthesia ◦ Fetal monitoring ◦ Sterilization ◦ Spontaneous, cephalic, vaginal full-term, single liveborn infant ◦ Don’t use with any other codes from chapter 15 ◦ Use additional outcome of delivery code Z37.0 © Kathleen Peterson, MS, RHIA, CCS 17 Chapter 15 codes may distinguish between preexisting conditions and those due to pregnancy ◦ Pre-existing hypertension – see category O10 ◦ Gestational [pregnancy-induced] hypertension – see categories O13, O14, O15 ◦ Pre-existing diabetes mellitus – see category O24, with specific codes from E08-E13 ◦ Gestational [pregnancy-induced] diabetes – O24.4- © Kathleen Peterson, MS, RHIA, CCS 18 O30 Twin, Triplet, Quadruplet, and other specified multiple gestation ◦ Number of placentas ◦ Number of amniotic sacs O31 Complications specific to multiple gestations ◦ When assigning codes from O31, you must also assign a code from O30 © Kathleen Peterson, MS, RHIA, CCS 19 Beginning with category O31, some category / subcategory codes have instructional note about assigning 7th character ◦ 0 assigned for single gestation and multiple gestations where fetus is unspecified ◦ 1 -5 assigned for fetuses 1 through 5 ◦ 9 assigned for other fetus Example: Single pregnancy, 13 weeks gestation, with maternal care for Rh incompatibility ◦ O36.0910 (Maternal care for other Rh antibodies, single gestation) ◦ Z3A.13 Weeks of gestation – 13 weeks © Kathleen Peterson, MS, RHIA, CCS 20 Assign ICD-10-CM codes for: Case 1 Intrauterine pregnancy, 12 weeks gestation, undelivered with mild hyperemesis gravidarium Case 2: Intrauterine pregnancy at 40 weeks gestation, delivered; Assisted spontaneous vaginal delivery, left occipitoanterior [presentation]; Single liveborn infant. © Kathleen Peterson, MS, RHIA, CCS 21 Encounter for an HIV-related illness O98.71- Human immunodeficiency virus [HIV] disease complicating pregnancy ◦ Also report B20 for symptomatic HIV disease /AIDS Encounter for asymptomatic HIV infection status O98.71- Human immunodeficiency virus [HIV] disease complicating pregnancy ◦ Also report Z21for asymptomatic HIV infection status © Kathleen Peterson, MS, RHIA, CCS 22 Report a code from O24.- Diabetes mellitus in pregnancy, childbirth, and puerperium ◦ Also assign code from categories E08-E13 for type of diabetes and any specific complications and/or manifestations For diabetes which is treated with insulin, assign Z79.4, Long-term (current) use of insulin © Kathleen Peterson, MS, RHIA, CCS 23 Occurs during 2nd and 3rd trimesters in patients without pre-pregnancy diagnosis of diabetes mellitus Assign code from O24.4- Gestational diabetes mellitus ◦ Provider must document how the gestational diabetes is controlled By diet or by insulin By both diet and insulin – use Z79.4 as additional code For abnormal glucose tolerance test during pregnancy, assign O99.810 © Kathleen Peterson, MS, RHIA, CCS 24 Alcohol use during pregnancy ◦ O99.31- [use 6th character to identify trimester] ◦ Use additional code from F10.- Alcohol related disorders to identify manifestations of alcohol use Tobacco use during pregnancy ◦ O99.33- [use 6th character to identify trimester] ◦ Use additional code from F17.- documented nicotine dependence or Z72.0 documented tobacco use Drug use during pregnancy ◦ O99.32- [use 6th character to identify trimester] ◦ Use additional code from F11-F16 & F18-F19 to identify manifestations of drug use © Kathleen Peterson, MS, RHIA, CCS 25 Maternal infectious and parasitic diseases ◦ O98.- [use 6th character to identify trimester] ◦ Use additional code (chapter 1), to identify specific infectious or parasitic diseases Other maternal diseases complicating pregnancy ◦ Anemia, diseases of specific body systems) ◦ O99.- [use 6th character to identify trimester] ◦ Follow instructional notes to use additional codes for specific disease O99.82- Strep B carrier status [use 6th character to identify trimester] Maternal malignant neoplasms, traumatic injuries & abuse ◦ O9A.- [use 6th character to identify trimester] ◦ Use additional code (from specific chapter) to identify the condition © Kathleen Peterson, MS, RHIA, CCS 26 Assign ICD-10-CM codes for: Case 1 Rubella in female patient at 14 weeks gestation, single fetus, undelivered Case 2: Prenatal visit for a 30-year-old female who developed gestational diabetes at 26 weeks gestation; treated by diet. Case 3: Female patient at 10 weeks gestation with acute pyelonephritis © Kathleen Peterson, MS, RHIA, CCS 27
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