Chapter 15. Pregnancy, Childbirth, and the Puerperium O00-O9A Official Coding Guidelines: Section I.C.15
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1 Chapter 15 Pregnancy, Childbirth, and the Puerperium O00-O9A Official Coding Guidelines: Section I.C.15
2 Sections/Blocks in Chapter 15 Pregnancy with abortive outcome (O00 O08) Supervision of high risk pregnancy (O09) Edema, proteinuria and hypertensive disorders in pregnancy, childbirth and the puerperium (O10 O16) Other maternal disorders predominantly related to pregnancy (O20 O29) Maternal care related to the fetus and amniotic cavity and possible delivery problems (O30 O48) Complications of labor and delivery (O60 O77) Encounter for delivery (O80 O82) Complications predominantly related to the puerperium (O85 O92) Other obstetric conditions, not elsewhere classified (O94 O9A) 2
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4 Z3A Weeks of Gestation 4
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23 Coding Exercises y.o. primigravida presented at 29 weeks with uncontrolled gestational diabetes O Gestational DM in pregnancy, unspecified control Variable is diet or insulin controlled What about uncontrolled? Diabetes out of control R73.0 excludes gestational DM 29 Weeks Z3A.29 Pregnancy, weeks of gestation, years old O Pregnancy, complicated by, young mother primigravida 29 week is third trimester 23
24 Coding Exercises year old female admitted 5 days after delivery with puerperal sepsis secondary to E. coli. O85 Puerperal Sepsis What about the organism? B96.20 Infection, Eschericia coli, as cause of disease classified elswhere 24
25 Coding Exercise Patient is a 35 year old G3, P2, Ab0, admitted for induction of labor due to severe preeclampsia and late decelerations. Patient had essential hypertension before pregnancy. Labor induced with Pitocin. However, due to persistent late decelerations, patient underwent primary low cervical Cesarean section of 6 pounds 4 ounces live born male. Patient was 36 weeks. Patient also had a Pomeroy tubal ligation for sterilization 25
26 Principal Diagnosis: O11.3 Pre eclampsia with pre existing HTN Use an additional code Pre existing essential hypertension complicating childbirth O76 Abnormality in fetal heart rate and rhythm complicating labor and delivery Delivery, complicated, by, fetal, heart rate or rhythm O61.0 Failed Induction of labor O60.14x0 Preterm labor third trimester with preterm delivery third trimester; 7 th character 0 for single newborns Z3A weeks gestation of pregnancy Z37.0 Outcome Single live born infant O Year Old Pregnancy, complicated by, elderly, multigravida 26
27 10D00Z1 Low cervical C Section Root Operation EXTRACTION Pulling or stripping out or off all or a portion of a body part by the use of force 3E033VJ Induction of labor with Pitocin Root Operation Introduction Putting in or on a therapeutic, diagnostic, nutritional, physiological, or prophylactic substance except blood or blood products Pomeroy Tubal Ligation Root Operation OCCLUSION OUL70ZZ Completely closing an orifice or the lumen of a tubular body part Root Operation EXCISION OUB70ZZ Cutting out or off, without replacement, a portion of a body part 27
28 Image of Pomeroy Procedure Excision: Cutting out or off, without replacement, a portion of a body part Occlusion: Completely closing an orifice or the lumen of a tubular body part Resection: Cutting out or off, without replacement, all of a body part 28
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