Advanced ICD-10-CM/PCS Coding for OB/Pregnancy

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1 Advanced ICD-10-CM/PCS Coding for OB/Pregnancy October 14, 2014 Karen Feltner, RHIA, CCS Plan for Today What are we discussing today? What is different in ICD-10-CM for pregnancy? What about ICD-10-PCS for obstetric procedures? We will try some coding examples 1

2 Latest on Implementation Another delay was implemented with passage of H.R. 4302, Protecting Access to Medicare Act of 2014, mainly creates a temporary fix to the Medicare sustainable growth rate (SGR) on March 31, This act prohibits implementation before October 1, 2015 This delay was not expected by CMS as evidenced by the announcement of no further delay in February How Are They Similar? ICD-9-CM and ICD-10-CM are alpha numeric. ICD-9-CM uses alpha characters V and E as first character in some codes Characters 2-5 are numeric ICD-10-CM uses alpha and numeric characters. The first character is an alpha character. Character 2 is a numeric character. Characters 3 through 7 may be alpha or numeric. The letter U is not used in ICD-10-CM A decimal is used after the third character for both coding systems. 2

3 How They are Similar Conventions common to both systems Boldface type, italicized type, includes notes, inclusion notes Abbreviations NEC -Not Elsewhere Classifiable NOS-Not Otherwise Specified Instructional notes See notes-mandatory cross references Must look elsewhere for correct code See also notes-recommended reference to alternate terms More specific code may be found at alternate term Code First/Use Additional Code Code Also Structure of ICD-10-CM Codes ICD-10-CM codes may consist of up to seven characters, with the seventh character extensions representing visit encounter or sequelae for injuries and external causes. 3

4 What s Different? Two types of Excludes notes Excludes1 notes, Excludes2 notes Codes may be incomplete in Index How do we identify an incomplete code in the ICD-10-CM index? Under main term Pregnancy, complicated by abnormal, abnormality cervix O34.4- causing obstructed labor O65.5 Placeholder Character - X The 7 th character is required for some codes. No 7 th character = invalid code What happens if the code does not have 6 characters and a 7 th character is required We now have a placeholder character- X used to fill the code as needed The X is used to fill the code so the 7 th character is in the 7 th position. 4

5 What is the same? Main terms Pregnancy Delivery Outcome of Delivery Puerperal, puerperium Postpartum period is still 6 weeks after delivery. Definition of Normal Delivery O80 is the same Outcome of Delivery This is the same in ICD-10-CM Index term- Outcome of Delivery Number of babies Liveborn or stillborn If multiples, status of siblings-all liveborn, all stillborn or combination of both liveborn and stillborn 5

6 Normal Delivery O80 One baby liveborn No assistance, can be with or without episiotomy-no forceps or version Cephalic presentation (LOA, ROA, ROP, LOP, vertex) Any antepartum conditions have resolved No postpartum complications during delivery encounter Abortion Definition ICD-10-CM: The expulsion or extraction of all or part of the placenta or membrane with an estimated gestation of less than 20 completed weeks is considered an abortive outcome (abortion). ICD-9-CM: The expulsion or extraction of all or part of the placenta with or without an identifiable fetus weighing less than 500 grams or with less than an estimated 22 weeks gestational age. 6

7 Pregnancy in ICD-10-CM New codes to be reported Number of weeks gestation Codes may require identification of trimester of when complication began Some codes require identification of which fetus is affected by a condition 13 Weeks Gestation Code Chapter 15 Pregnancy, childbirth and the puerperium (O00-O9A) Use additional code from category Z3A, Weeks of gestation, to identify the specific week of the pregnancy Index term, Pregnancy, Weeks of gestation» Individual code for weeks 8 42» Less than 8 weeks Z3A.01» Greater than 42 weeks Z3A.49» All pregnancy codes-including abortion, missed abortion, ectopic pregnancy and abnormal products of conception. 7

8 Trimester Trimesters are counted from the first day of the last menstrual period. They are defined as follows: 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 In addition to Trimester Codes may also have description that state In childbirth In puerperium Unspecified trimester 8

9 Selection of Trimester Code selection is based on the provider s documentation of gestational age (weeks) The trimester character is chosen based on the trimester at the time of the admission/encounter should be assigned. If a patient is admitted during one trimester and continues into another trimester, trimester character is chosen based on when condition develops. If patient delivers during the stay AND there is an in childbirth option for the code than code is selected. Example of OB Code Example of ICD-10-CM OB Code O Unspecified pre-existing diabetes mellitus in pregnancy, first trimester O Unspecified pre-existing diabetes mellitus in pregnancy, second trimester O Unspecified pre-existing diabetes mellitus in pregnancy, third trimester O Unspecified pre-existing diabetes mellitus in pregnancy, unspecified trimester O24.32 Unspecified pre-existing diabetes mellitus in childbirth O24.33 Unspecified pre-existing diabetes mellitus in the puerperium 9

10 More Examples of OB Code More Examples of ICD-10-CM OB Code O65.0 Obstructed labor due to deformed pelvis O21.0 Mild hyperemesis gravidarum O44.10 Placenta previa with hemorrhage, unspecified trimester O44.11 Placenta previa with hemorrhage, first trimester O44.12 Placenta previa with hemorrhage, second trimester O44.13 Placenta previa with hemorrhage, third trimester Which Fetus is Affected? From the Tabular List, specifically code O60.1 One of the following 7th characters is to be assigned to each code under subcategory O th character 0 is for single gestations and multiple gestations where the fetus is unspecified. 7th characters 1 through 9 are for cases of multiple gestations to identify the fetus for which the code applies. The appropriate code from category O30, Multiple gestation, must also be assigned when assigning a code from subcategory O60.1 that has a 7th character of 1 through 9. 0 not applicable or unspecified 1 fetus 1 2 fetus 2 3 fetus 3 4 fetus 4 5 fetus 5 9 other fetus Fetus A designation would equal fetus 1, Fetus B designation would equal fetus 2 per Coding Clinic 20 10

11 Which Fetus is Affected? O60.1 Preterm labor with preterm delivery O60.12 Preterm labor second trimester with preterm delivery second trimester O60.12X0 would be code for single gestation O60.12X1 would be code for multiple gestation and condition affecting fetus 1 O60.12X2 would be code for multiple gestation pregnancy and condition affecting fetus 2 Multiple codes may be required if multiple gestations and all fetus affected by condition. Example of OB Combination Code Patient is at 20 weeks gestation with uncomplicated twin pregnancy, monochorionic/monoamniotic Index Entry Pregnancy, twin O conjoined O dichorionic/diamniotic(two placenta, two amniotic sacs) O monochorionic/diamniotic(one placenta, two amniotic sacs) O monochorionic/monoamniotic(one placenta, one amniotic sac) O unable to determine number of placenta and number of amniotic sacs O unspecified number of placenta and unspecified number of amniotic sacs O

12 Tabular Entry O Twin pregnancy, monochorionic/monoamniotic, first trimester O Twin pregnancy, monochorionic/monoamniotic, second trimester O Twin pregnancy, monochorionic/monoamniotic, third trimester O Twin pregnancy, monochorionic/monoamniotic unspecified trimester Codes to be reported for diagnosis of twin pregnancy, monochorionic/monoamniotic at 20 weeks gestation O30.012, Z3A Maternal Diseases This would include any conditions the mother may have that were present prior to pregnancy Many conditions require an additional code to provide specification O22.2 or O22.3 O24 O99 There are use additional code notes in the Tabular List 12

13 Pregnancy and Combination Codes Obstructed labor in ICD-10-CM uses combination codes for reporting Some still require two codes Some of the codes require a 7 th character to identify fetus affected Obstructed labor due to brow presentation O64.3XX0 code would represented singleton pregnancy with obstructed labor due to brow presentation Obstructed labor due to large fetus O66.2 code would represented obstructed labor due to large fetus 25 ICD-10-PCS Conventions of the classification system require seven CHARACTERS in each code. All numbers 0-9 are used as are all alphabetic characters EXCEPT the letter I and the letter O Section Body System Root Operation Body Part Approach Device Qualifier 26 13

14 ICD-10-PCS and Obstetrics Medical Surgical Section Begin with a 0 31 root operations 31 body systems Obstetric Section Begin with a 1 12 root operations 1 body system 3 body parts ICD-10-PCS and Obstetrics Coding Guideline C1. Procedures performed on the products of conception are coded to the Obstetrics section. Procedures performed on the pregnant female other than the products of conception are coded to the appropriate root operation in the Medical and Surgical section. Episiotomy is coded in Medical Surgical section Forceps delivery is coded in Obstetrics section Tubal ligation is coded in Mecical Surgical section D&C for retained placenta is coded in Obstetrics section 28 14

15 Root Operations There are two root operations specific to Obstetrics section Abortion: Artificial terminating a pregnancy Delivery: Assisting products of conception from the genital canal Other root operations have same definition as in Medical-Surgical section Remember body part is Products of Conception when applying definition Vaginal Delivery Manual Assisted Delivery ICD-9-CM: ICD-10-PCS: 10E0XZZ Cesarean Delivery ICD-9-CM: Low transverse c-section 74.1 ICD-10-PCS: 10D00Z1 (low cervical) Root operation Extraction Forceps delivery-qualifier identifies type of forceps 10D07Z3 (low forceps) D&C for retained products of conception 10D17ZZ Removal of ectopic pregnancy 10D27ZZ 15

16 Coding Repair of Delivery Injuries Perineal lacerations during delivery First-degree tears involve damage to the fourchette and vaginal mucosa, and underlying muscles are exposed but not torn. Second-degree tears can include the posterior vaginal walls, pelvic floor, and perineal muscles, but the anal sphincter is intact. Third-degree tears extend to the anal sphincter and can include the rectovaginal septum, but the rectal mucosa is intact. Fourth-degree tears involve the rectal and/or anal mucosa. 31 Coding Perineal Lacerations The ICD-10-PCS codes will vary First degree tear-repair of perineum 0WQN0ZZ Resulting DRG is still in the OB DRGs Second degree tear-?? Can be tear of posterior vaginal wall, pelvic floor or perineal musclehow do we code this Documentation frequently only states Repair 2 nd degree tear but specific site not identified? Vaginal Wall = 0UQG0ZZ (Female Reproductive system) Perineal Muscle = 0KQM0ZZ (Muscle body system) Pelvic floor= repair perineum 0WQN0ZZ 32 16

17 Coding Perineal Lacerations The ICD-10-PCS codes will vary Third degree tear- Involves anal sphincter 0DQR0ZZ May send to non-ob DRG 983 Extensive OR Procedure unrelated to Principal diagnosis w/o CC/MCC Fourth degree tear-involves rectal and/or anal mucosa Documentation frequently only states Repair 4 th degree tear but specific site not identified? Rectum= 0DQP0ZZ Anus = 0DQQ0ZZ 33 Perineal Lacerations From the ICD-10-CM and ICD-10-PCS Coding Handbook by Nelly Leon-Chisen, RHIA When more than one degree is mentioned, only the code for the highest degree is assigned. The appropriate surgical repair code is assigned depending on the tissue repaired (e.g., for open repair of the vaginal wall, assign code 0UQG0ZZ) with the body part specifying the deepest layer repaired 34 17

18 Obstetrics Documentation for ancillary OB procedures are not always well documented by physician Artificial rupture of membranes Fetal monitoring Methods of induction (Some are coded in Introduction section) Pitocin induction 3E033VJ Cervidil induction3e0p7gc AROM 10907ZC Cervical dilatation 0U7C7ZZ 35 Coding Example #1 14 year old primigravida presents to the Emergency Department at 16 weeks gestation with vomiting and dehydration. Final diagnosis: Young patient with hyperemesis gravidarum with dehydration O21.1 Hyperemesis gravidarum with metabolic disturbance E86.0 Dehydration O Young primigravida, second trimester Z3A weeks gestation 18

19 Coding Example #2 30 year old G2P1 female at 39 weeks gestation presents in labor. Patient progressed well and delivered vaginally over an intact perineum. Single liveborn female. AROM performed. O80 Normal Delivery Z3A.39 Gestation weeks Z37.0 Outcome of Delivery 10907ZC AROM (drainage) 10E0XZZ Manually assisted delivery Coding Example #3 38 year old primigravida with 33 week twin, monoamniotic/monochorionic gestation presents in labor. She undergoes low cesarean section due to maternal exhaustation. Cord around neck baby A-no compression. Both male infants liveborn. Codes? 19

20 Coding Example #3 Answers O60.14X1 Preterm labor & delivery-baby 1 O60.14X2 Preterm labor & delivery-baby 2 O75.81 Maternal exhaustion O69.81X1 Cord around neck w/o compression baby 1 O30.13 Twin gestation, mono/mono O year old primigravida Z37.2 Outcome of delivery, both liveborn Z3A.33 Weeks gestation 10D00Z1-Low cervical C-section Coding Example #4 25 year old presents to Emergency Department, three weeks after normal vaginal delivery with severe pain and swelling of the right breast. She is breastfeeding her infant. She is febrile. Discharge diagnosis: Postpartum mastitis O

21 Coding example #5 20 year old presents with mild vaginal bleeding. She reports she had positive pregnancy test & was 10 weeks along. Exam reveals products of conception in the cervical os. She is taken to surgery and undergoes a D&C for retained products of conception after spontaneous abortion. O03.4 Incomplete spontaneous abortion Z3A.10 10D17ZZ (extraction-retained products of conception) Questions-Comments ICD-10-CM 21

22 Resources nate-votes-on-icd-10-delay-bill/ content/uploads/2011/10/ icd- 10-Cincinnati_FINAL-Leon-Chisen.pdf Barta, Ann. "Obstetric Coding in ICD-10- CM/PCS." Journal of AHIMA 81, no.6 (June 2010):