1/30/2014. Specialty Code Set Training Obstetrics. Pregnancy
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1 Specialty Code Set Training Obstetrics Peggy Stilley, CPC, CPMA, CPC-I, CPB, COBGC Director, ICD-10 Training and Education No part of this presentation may be reproduced or transmitted in any form or by any means (graphically, electronically, or mechanically, including photocopying, recording, or taping) without the expressed written permission of AAPC. 2 Pregnancy Chapter 15 for pregnancy, childbirth, and the puerperium are reported with codes O00-O9A. New concepts for code selection include trimesters in most categories Use of 7 th character to identify the fetus affected by a condition Additional category Z3A to report weeks of gestation 1
2 Trimesters Trimesters are identified as follows: 1 st Trimester - less than 14 weeks, 0 days 2 nd Trimester 14 weeks 0 days to less than 28 weeks 0 days 3 rd Trimester 28 weeks, 0 days to delivery Trimester will not be a component in conditions that occur in specific trimesters. Patient admitted for a complication with an extended stay that crosses trimesters, report the trimester in which the complication developed. Weeks of Gestation Lookup pregnancy, weeks of gestation Z3A.00 Weeks of gestation not specified Z3A weeks gestation Z3A.01 Less than 8 weeks gestation Z3A weeks gestation Z3A.08 8 weeks gestation Z3A weeks gestation Z3A.09 9 weeks gestation Z3A weeks gestation Z3A weeks gestation Z3A weeks gestation Z3A weeks gestation Z3A weeks gestation Z3A weeks gestation Z3A weeks gestation Z3A weeks gestation Z3A.49 > Than 42 weeks gestation 7 th Character Fetal Extension 0 Unspecified, singleton 1 Fetus 1 2 Fetus 2 3 Fetus 3 4 Fetus 4 5 Fetus 5 9 Other fetus For use with Category O31, O33.3 O33.7, O35, O36, O40, O41, O60.1 O60.2, O64, and O69 2
3 Coding Tips Codes from chapter 15 take sequencing priority over all other chapters and are only reported on the maternal chart. If the provider documents that a condition is not affecting the pregnancy, the code for the condition is used, followed by Z33.1 Pregnant state, incidental A pregnant patient sprains her ankle when she misses a step walking to her front door. The provider wraps the ankle with an ace bandage and instructs her to stay off her ankle. The physician documents the condition is not affecting the pregnancy. S93.401A Sprain of unspecified ligament of the right ankle, initial encounter Z33.1 Pregnant state, incidental Ectopic Pregnancy Ectopic pregnancy occurs when an embryo implants outside the uterine cavity Most common site is fallopian tube Symptoms include Pain, abdominal or pelvic Light bleeding Code selection Anatomic site (cervical, tubal, ovarian, abdominal) Associated complications (hemorrhage, infection, endometritis) 3
4 Ectopic Pregnancy Abdominal pregnancy Tubal pregnancy Ovarian pregnancy Other ectopic pregnancy O00.0 O00.1 O00.2 O00.8 * Use additional code from O08 to identify any associated complication * O00.0 contains Excludes I note for a viable fetus in ectopic pregnancy (O36.7) * Use additional code from category Z3A, weeks of gestation An ultrasound confirms a patient is 8 weeks pregnant with a tubal ectopic pregnancy. O00.1 Tubal pregnancy Z3A.08 8 weeks gestation of pregnancy Missed Abortion Definition is early fetal death before 20 weeks, with retained fetus More specific codes are available for blighted ovum, molar pregnancy After 20 weeks gestation code for IUFD 4
5 Pregnancy with Abortive Outcomes Missed Abortion Intrauterine Fetal Death < 20 weeks gestation > 20 weeks gestation Hydatidiform Mole Blighted ovum and nonhydatidiform mole O02.1 Z3A- wk of gestation O36.4 Z3A.- wk gestation Requires a 7 th character fetal extension O01.0 classical O01.1 Incomplete O01.9 Unspecified Z3A.- wk gestation O02.0 blighted ovum Z3A.- wk gestation Use additional code Use additional code from O08 to identify any from O08 to identify associated complication any associated complication A pregnant patient presents for a 16 week routine ultrasound. There is no fetal heartbeat on US and the provider confirms a missed abortion. O02.1 early fetal death, before completion of 20 weeks gestation, with retention of fetus. Look-up is abortion, missed Diabetes in Pregnancy O24- Diabetes in pregnancy Categories are specific to in pregnancy, childbirth, puerperium Codes based on Type of Diabetes O24.0- Type I (Pre-existing DM) O24.1- Type II (Pre-existing DM) may require additional codes for manifestations ((E10 or E11) Gestational DM includes a final character to identify the method of control ( diet, insulin, unspecified) 5
6 O DM, Type I, first trimester O DM, Type II, first trimester O DM, Type I, second trimester O DM, Type II, second trimester O DM, Type I, third trimester O DM, Type II, third trimester O DM, Type I, unspecified trimester O DM, Type II, unspecified trimester O24.02 DM, Type I in childbirth O24.12 DM, Type II in childbirth O24.03 DM, Type I in puerperium O24.13 DM, Type II in puerperium Use additional code from Category E10 to further identify any manifestations Diabetes in Pregnancy Use additional code from Category E11 to identify any manifestations Use Z79.4 long-term use of insulin Gestational Diabetes Category O24.41 Gestational Diabetes in pregnancy O diet controlled O insulin controlled O unspecified control Category O24.42 Gestational Diabetes in childbirth O diet controlled O insulin controlled O unspecified control Category O24.43 Gestational Diabetes in the puerperium O diet controlled O insulin controlled O unspecified control A 24 week pregnant patient with Type I diabetes develops a diabetic foot ulcer on her left heel involving breakdown of the skin. O Pre-existing diabetes, Type 1, in pregnancy, second trimester E Type I diabetes mellitus with foot ulcer L Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of the skin Z3A weeks gestation of pregnancy 6
7 OB patient with gestational diabetes presents for a regular prenatal visit. She is 29.3 weeks, she feels well, taking meds as prescribed. She tired to follow her diet and exercises sporatically. Patient uses One-Touch Ultra and keeps a log book. Glucose readings are in range with no hypoglycemic episodes. Patient will have bi-weekly NST and BPP until delivery. O Gestational diabetes, diet controlled Z3A.29 Weeks of gestation Alcohol and Drug Dependence Alcohol and drug abuse in pregnancy can lead to developmental delays, birth defect, and behavioral changes O99.31 Alcohol use in pregnancy Use additional code from F10 to identify manifestation of alcohol use O99.32 Drug use in pregnancy Use additional code from F11-F16 and F18-F19 to identify manifestation of drug use A patient 35 weeks pregnant has been using cocaine throughout her pregnancy. She has been counseled on the dangers but is unable to stop. O Drug use complicating pregnancy, third trimester F14.20 Cocaine Dependence, uncomplicated Z3A weeks gestation of pregnancy 7
8 Preeclampsia Abnormal condition with BP and high level of protein Serious for mother and fetus Generally occurs in 3 rd Trimester Pre-eclampsia Symptoms include: Swelling in feel, legs, hands, face Rapid weight gain Severe headaches Abdominal pain Vomiting and nausea O14.00 O14.02 O14.03 O14.10 O14.12 O14.13 O14.20 O14.22 O14.23 O14.90 O14.92 O14.93 Pre-eclampsia Mild to moderate pre-eclampsia, Unspecified trimester Mild to moderate pre-eclampsia, Second trimester Mild to moderate pre-eclampsia, Third Trimester Severe pre-eclampsia, Unspecified trimester Severe pre-eclampsia, Second trimester Severe pre-eclampsia, Third trimester HELLP syndrome, unspecified trimester HELLP syndrome, second trimester HELLP syndrome, third trimester Unspecified pre-eclampsia, unspecified trimester Unspecified pre-eclampsia, second trimester Unspecified pre-eclampsia, third trimester 8
9 A patient 29 weeks pregnant complains of excessive swelling in her feet. Her blood pressure is high and her urine shows high levels of protein. The patient is diagnosed with mild pre-eclampsia. O14.03 Mild to moderate preeclampsia, third trimester Z3A weeks gestation of pregnancy Multiple Gestations Documentation for multiple gestations must include: Number of gestations Number of amniotic sacs and number of placentae 7 th character is required to identify the fetus for which the complication affects. 9
10 Multiple Gestation Category O30 multiple gestations Category O31 complications of multiple gestations 23-year-old G3P2002 presents for US with MC/DA twins. Gestational age is No complaints, no fluid leaking, labor precautions given, and fetal kick counts explained. O Twin pregnancy, monochorionic /diamniotic third trimester Z3A weeks gestation A patient 16 week pregnant with triplets comes to the office for her routine OB appointment. O Triplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, second trimester Z3A weeks gestation of pregnancy 10
11 Preterm Labor Presence of uterine contractions of sufficient frequency and intensity to change cervical effacement and dilation of a pregnancy prior to term Occurring weeks Documentation must include: Trimester of pregnancy Weeks of gestation Preterm Labor O60.00 Preterm labor without delivery, unspecified trimester O60.02 Preterm labor without delivery, second trimester O60.03 Preterm labor without delivery, third trimester O60.10 Preterm labor with preterm delivery, unspecified trimester O60.12 Preterm labor second trimester, with PT delivery second trimester O60.13 Preterm labor second trimester, with PT delivery third trimester O60.14 Preterm labor third trimester, with PT delivery third trimester False Labor O47.00 False labor before 37 weeks gestation, unspecified trimester O47.02 False labor before 37 weeks gestation, second trimester O47.03 False labor before 37 weeks gestation, third trimester O47.1 False labor at or after 37 completed weeks gestation 11
12 Delivery Principal code is the circumstance of delivery Code selection is based on Type of delivery Cesarean Breech Normal, vaginal delivery When multiple complications occur all conditions reported Category Z37 identifies the Outcome of delivery Coding Tips Normal vaginal deliveries are reported with O80, encounter for full-term uncomplicated delivery Z37.0 Single liveborn (only code to be used with O80) A pregnant patient delivers twins at 30 weeks gestation. Fetus 1 is delivered vaginally. During the delivery, fetus 2 turned into the transverse position during labor. The decision is made to perform a cesarean to deliver the second baby. O32.2XX2 Maternal care for transverse and oblique lie, fetus 2 O60.14X0 Preterm labor third trimester with preterm delivery third trimester, not applicable or unspecified O Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, third trimester Z3A weeks gestation of pregnancy Z37.2 Twins, both liveborn 12
13 Cesarean Delivery Codes are specific to: Reason for the cesarean Malposition Disproportion Maternal condition Scheduled Cesarean Delivery by planned cesarean, with onset of labor Reason for the planned cesarean (CPD, previous cesarean) 13
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