Chapter-specific guidelines (ICD-10-CM chapters 15-21)

Chapter 6


Chapter-specific guidelines (ICD-10-CM chapters 15-21)




Learning objectives


After completing this chapter you should be able to


1. Review the pregnancy, childbirth, and puerperium coding.


2. Report services of certain conditions originating in the perinatal period.


3. Examine the congenital malformations, deformities, and chromosomal abnormalities.


4. Define the rules of symptoms, signs, and abnormal clinical and laboratory findings that are not elsewhere classified.


5. Identify the elements of coding injury, poisonings, and certain other consequences of external causes.


NOTE: The 2012 ICD-10-CM DRAFT was used in this text.



Pregnancy, childbirth, and the puerperium


Chapter 15, Pregnancy, Childbirth, and the Puerperium (O00-O9A) of the Tabular of the I-10 is a difficult chapter from which to report diagnoses. One reason is that pregnancy and childbirth are natural functions, and physicians often overlook documentation of diagnoses that should be reported. Another reason the coding is complex is that there is extensive use of multiple coding in I-10 Chapter 15. There are instructions throughout this chapter that must be read thoroughly. Obstetric coding can also be difficult because you may not use this chapter as frequently as some of the other chapters, so you won’t be as familiar with the notes and coding instructions. Any condition that occurs during pregnancy, childbirth, or the puerperium is considered to be a complication unless the attending physician specifically documents that it neither affects the pregnancy nor is affected by the pregnancy.



ICD-10 OFFICIAL GUIDELINES FOR CODING AND REPORTING



SECTION I.C.15. Chapter 15: pregnancy, childbirth, and the puerperium (O00-O9a)




a. General Rules for Obstetric Cases



c. Pre-existing conditions versus conditions due to the pregnancy





First-listed diagnosis in normal pregnancy



ICD-10 OFFICIAL GUIDELINES FOR CODING AND REPORTING




Routine outpatient prenatal visits are reported with codes from category Z34, Encounter for supervision of normal pregnancy, as the first-listed diagnosis. If there is any type of complication, such as those reported with O00-O9A, Z34 codes cannot be reported. For example, if the patient encounter was for the supervision of a normal first pregnancy in the first trimester, assign Z34.01, Encounter for supervision of normal first pregnancy, first trimester.



First-listed diagnosis in high-risk patients



ICD-10 OFFICIAL GUIDELINES FOR CODING AND REPORTING




Some patients are considered high-risk for complication during pregnancy, such as neonatal death. When encounters are for high-risk patients, report a code from category O09, Supervision of high-risk pregnancy. For example, a patient in her first trimester presents for an office visit with her obstetrician. The patient’s first pregnancy ended in neonatal death. Report O09.291, Supervision of pregnancy with other poor reproductive or obstetric history, first trimester.



First-listed diagnosis for delivery



ICD-10 OFFICIAL GUIDELINES FOR CODING AND REPORTING



SECTION I.C.15 Chapter 15: pregnancy, childbirth, and the puerperium ((O00-O9a))




b. Selection of OB Principal or First-listed Diagnosis



3) Episodes when no delivery occurs



4) When a delivery occurs



5) Outcome of delivery




The outcome of delivery is indicated only on the mother’s medical record. For example, the mother gives birth to a single live born, reported with Z37.0. The outcome of delivery is only reported once on the mother’s record and is not reported on subsequent encounters.



Trimesters



ICD-10 OFFICIAL GUIDELINES FOR CODING AND REPORTING



SECTION I.C.15 Chapter 15: pregnancy, childbirth, and the puerperium ((O00-O9a))




a. General Rules for Obstetric cases



3) Final character for trimester



The majority of codes in Chapter 15 have a final character indicating the trimester of pregnancy. The timeframes for the trimesters are indicated at the beginning of the chapter. If trimester is not a component of a code it is because the condition always occurs in a specific trimester, or the concept of trimester of pregnancy is not applicable. Certain codes have characters for only certain trimesters because the condition does not occur in all trimesters, but it may occur in more than just one.


Assignment of the final character for trimester should be based on provider’s documentation of the trimester (or number of weeks) for the current admission/encounter. This applies to the assignment of trimester for pre-existing conditions as well as those that develop during or are due to the pregnancy. The provider’s documentation of the number of weeks may be used to assign the appropriate code identifying the trimester.


Whenever delivery occurs during the current admission, and there is an “in childbirth” option for the obstetric complication being coded, the “in childbirth” code should be assigned.


4) Selection of trimester for inpatient admissions that encompass more than one trimesters



5) Unspecified trimester




Trimesters are indicated on many of the codes in Chapter 15. Trimesters are calculated from the first day of the last menstrual period (LMP) and are as follows:















 less than 14 weeks 0 days from LMP

 14 weeks 0 days to less than 28 weeks 0 days from LMP

 28 weeks 0 days from LMP until delivery occurs


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Codes from Chapter 15 have priority over codes from other chapters. Although additional codes may be reported for further detail, the Chapter 15 code is first-listed. It is the physician’s responsibility to document that the condition or conditions being treated are not affecting the pregnancy. In the absence of this documentation, assume the condition is affecting the pregnancy.


There are codes for unspecified trimester; however, they should only be used if there is no further information available to determine the correct trimester.



QUICK CHECK 6-1image




There are times when the first-listed diagnosis for a pregnant female will not be a Chapter 15 code:



There are conditions that are due to pregnancy, and those same conditions that may have been present prior to pregnancy, such as hypertension, are shown in Figure 6-1. If the category does not state pre-existing or pregnancy-related condition, the category may be assigned to either.


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FIGURE 6–1 Pre-existing hypertension (From Buck CJ: 2012 ICD-10-CM Standard Edition DRAFT (Softbound), St. Louis, 2012, Saunders.)


Peripartum and postpartum periods



ICD-10 OFFICIAL GUIDELINES FOR CODING AND REPORTING



SECTION I.C.15. Chapter 15: pregnancy, childbirth, and the puerperium ((O00-O9a))




o. The Peripartum and Postpartum Periods



1) Peripartum and Postpartum periods



2) Peripartum and postpartum complication



3) Pregnancy-related complications after 6 week period



4) Admission for routine postpartum care following delivery outside hospital



5) Pregnancy associated cardiomyopathy




The time periods of pregnancy are:












 last month of pregnancy to 5 months postpartum

 immediately after delivery to 6 weeks after delivery


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If the patient has a pregnancy-related complication after the peripartum and postpartum periods of time, the physician must document that the condition is pregnancy-related in order to assign Chapter 15 codes.


If the mother delivers outside the hospital, report the first-listed diagnosis as Z39.0, Encounter for care and examination of mother immediately after delivery.



Normal delivery



ICD-10 OFFICIAL GUIDELINES FOR CODING AND REPORTING



SECTION I.C.15. Chapter 15: pregnancy, childbirth, and the puerperium ((O00-O9a))




n. Normal Delivery, Code O80



1) Encounter for full term uncomplicated delivery



2) Uncomplicated delivery with resolved antepartum complication



3) Outcome of delivery for O80




O80 is reported as the first-listed diagnosis for a full-term, uncomplicated delivery of a single, healthy infant without any complications before, during, or after the delivery. If the patient had antepartum complications, but that complication is not present at delivery, you can still report a normal delivery with O80.


The outcome of an O80 delivery is reported with Z37.0, Single live birth. No other outcome of delivery code would be correct to report with O80.



QUICK CHECK 6-2image







Hypertension in pregnancy



ICD-10 OFFICIAL GUIDELINES FOR CODING AND REPORTING




When hypertension is a pre-existing condition that complicates pregnancy, delivery, or the five-month period after delivery, report the condition with a category O10 code, Pre-existing hypertension complicating pregnancy, childbirth, and the puerperium. The category O10 code is the first-listed diagnosis, and a secondary code is assigned to report any hypertensive heart disease or hypertensive chronic kidney disease.



PRE-EXISTING HYPERTENSION Example


A pregnant patient is seen by her obstetrician in her first trimester for a routine prenatal check. The patient has pre-existing stage I hypertensive chronic kidney disease that is complicating her pregnancy.


Report O10.211, Pre-existing hypertensive chronic kidney disease complicating pregnancy, first trimester; and I12.9, Hypertensive chronic kidney disease with stage I through stage IV chronic kidney disease, or unspecified chronic kidney disease. The notes following code I12.9 state to use an additional code to identify the stage of chronic renal disease; therefore, add N18.1 (Disease, kidney, chronic, stage I).



Fetal conditions



ICD-10 OFFICIAL GUIDELINES FOR CODING AND REPORTING



SECTION I.C.15. Chapter 15: pregnancy, childbirth, and the puerperium ((O00-O9a))




e. Fetal Conditions Affecting the Management of the Mother



1) Codes from categories O35 and O36



2) In utero surgery




Categories O35 and O36 report fetal abnormalities or other fetal problems when these abnormalities or problems affect the care of the mother. If the abnormality or problem is present but does not affect the care of the mother, O35 and O36 are NOT reported. It is only when these conditions exist and do affect the mother’s care that O35 or O36 are reported.



TOOLBOXimage


Carol Jean is a 35-year-old alcoholic in her second trimester with a single fetus. She continues to consume 4-5 drinks daily that contain alcohol. Her OB/GYN is concerned about the slow growth of the fetus and has asked Dr. Zahn, a specialist in fetal alcohol disorders, to provide a consultation regarding suspected fetal alcohol syndrome (FAS).





Diabetes mellitus in pregnancy



ICD-10 OFFICIAL GUIDELINES FOR CODING AND REPORTING



SECTION I.C.15. Chapter 15: pregnancy, childbirth, and the puerperium ((O00-O9a))




g. Diabetes mellitus in pregnancy



h. Long term use of insulin



i. Gestational (pregnancy induced) diabetes



Gestational (pregnancy induced) diabetes can occur during the second and third trimester of pregnancy in women who were not diabetic prior to pregnancy. Gestational diabetes can cause complications in the pregnancy similar to those of pre-existing diabetes mellitus. It also puts the woman at greater risk of developing diabetes after the pregnancy. Codes for gestational diabetes are in subcategory O24.4, Gestational diabetes mellitus. No other code from category O24, Diabetes mellitus in pregnancy, childbirth, and the puerperium, should be used with a code from O24.4.


The codes under subcategory O24.4 include diet controlled and insulin controlled. If a patient with gestational diabetes is treated with both diet and insulin, only the code for insulin-controlled is required.


Code Z79.4, Long-term (current) use of insulin, should not be assigned with codes from subcategory O24.4.


An abnormal glucose tolerance in pregnancy is assigned a code from subcategory O99.81, Abnormal glucose complicating pregnancy, childbirth, and the puerperium.



Poorly controlled diabetes mellitus during pregnancy can lead to serious complications for both the mother and the fetus and may result in miscarriage or stillbirth. Type 1 diabetes is a condition in which little or no insulin is produced by the body and is controlled with administration of insulin. Type 2 diabetes is a condition in which too little insulin is produced or the body cannot use the insulin that is produced and is controlled with dietary restrictions and medications and/or insulin.


If the pregnant female has type 2 diabetes mellitus that is well controlled with the use of insulin or oral medication, you would report a code from category O24, Diabetes mellitus in pregnancy, childbirth, and the puerperium, as the first-listed diagnosis followed by a code to report the type of diabetes, E11.9, Type 2 diabetes mellitus without complications. If the patient’s diabetes has been and currently is being controlled with insulin, report Z79.4, Long-term (current) use of insulin, as a supplemental code.


Gestational diabetes is a type of diabetes that develops in the second or third trimester of pregnancy in women who did not have either type of diabetes prior to pregnancy. This type of diabetes may be controlled through dietary restrictions or insulin, depending on the severity of the condition and is reported with a code from category O24, Diabetes mellitus in pregnancy, childbirth, and the puerperium. Code Z79.4, Long-term (current) use of insulin, would not be assigned because the gestational diabetes is being treated with insulin.



imageExercise 6-1   Pregnancy, Childbirth, and the Puerperium


Complete the following in Chapter 6 of your “ICD-10-CM Online Training Modules:”


Online Lesson 1, Screens 1-17



Certain conditions originating in the perinatal period


Chapter 16, Newborn (Perinatal) Guidelines (P00-P96), contains codes for the perinatal period, which is before birth through 28 days after birth. The blocks in this chapter are as shown in Figure 6-3.


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FIGURE 6–3 Blocks in Chapter 16, Certain Conditions Originating in the Perinatal Period (P00-P96). (From Buck CJ: 2012 ICD-10-CM Standard Edition DRAFT (Softbound), St. Louis, 2012, Saunders.)


ICD-10 OFFICIAL GUIDELINES FOR CODING AND REPORTING


Certain conditions originating in the perinatal period



Codes from Chapter 16 are only for the newborn record and are never reported on the maternal record. These codes do not report congenital malformations, deformities, or chromosomal abnormalities; rather, those conditions are reported with codes in the Q00-Q99 range.



First-listed diagnosis



ICD-10 OFFICIAL GUIDELINES FOR CODING AND REPORTING




The first-listed diagnosis on the newborn record is a category Z38 code, Liveborn according to place of birth and type of delivery. This category is for use as the first-listed code on the initial record of a newborn. It is to be assigned for the initial birth record only, and it is never to be used on the mother’s record. For example, Z38.1, Single liveborn infant, born outside hospital, is reported only on the initial newborn record and is never reported on the mother’s record.



Congenital malformations, deformations and chromosomal abnormalities


Chapter 17, Congenital Malformations, Deformations and Chromosomal Abnormalities (Q00-Q99), in the I-10 Tabular describes congenital anomalies and conditions that originate in the perinatal period. The perinatal period extends through the 28 days following birth. The term perinatal applies only to the baby and postpartum applies to the mother. Codes from Chapter 17 can be assigned beyond the time frame of perinatal period, but as the chapter title indicates, the condition must have originated during the perinatal period.


The blocks of Chapter 17 are as illustrated in Figure 6–4.


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FIGURE 6–4 Blocks in Chapter 17, Congenital Malformations, Deformations and Chromosomal Abnormalities (Q00-Q99). (From Buck CJ: 2012 ICD-10-CM Standard Edition DRAFT (Softbound), St. Louis, 2012, Saunders.)


ICD-10 OFFICIAL GUIDELINES FOR CODING AND REPORTING



SECTION I.C.17. Chapter 17: congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99)


Assign an appropriate code(s) from categories Q00-Q99, Congenital malformations, deformations, and chromosomal abnormalities when a malformation/deformation or chromosomal abnormality is documented. A malformation/deformation/or chromosomal abnormality may be the principal/first-listed diagnosis on a record or a secondary diagnosis.


When a malformation/deformation/or chromosomal abnormality does not have a unique code assignment, assign additional code(s) for any manifestations that may be present.


When the code assignment specifically identifies the malformation/deformation/or chromosomal abnormality, manifestations that are an inherent component of the anomaly should not be coded separately. Additional codes should be assigned for manifestations that are not an inherent component.


Codes from Chapter 17 may be used throughout the life of the patient. If a congenital malformation or deformity has been corrected, a personal history code should be used to identify the history of the malformation or deformity. Although present at birth, malformation/deformation/or chromosomal abnormality may not be identified until later in life. Whenever the condition is diagnosed by the physician, it is appropriate to assign a code from codes Q00-Q99. For the birth admission, the appropriate code from category Z38, Liveborn infants, according to place of birth and type of delivery, should be sequenced as the principal diagnosis, followed by any congenital anomaly codes, Q00-Q99.


An anomaly is an abnormality of a structure or organ. Congenital anomaly means that it is an abnormality that one was born with. Some anomalies are noticeable and discovered at birth. In cases of other anomalies, it may be a number of months or even years before the anomaly is diagnosed. If there is a question as to whether a condition was acquired or congenital, you should review the record or query the physician. The physician must document the abnormality, and the abnormality may be either the first-listed diagnosis or an additional diagnosis.


If a patient is admitted for the purpose of birthing, report a code from category Z38, Liveborn infant according to type of birth, and sequence the Z38 code as the first-listed diagnosis. The Z38 code is assigned only once and on the birth record of the newborn because the Z38 code indicates the type of birth. If any other conditions or congenital anomalies are documented, report them as secondary diagnoses.



NEWBORN CONGENITAL ANOMALIES Example











Diagnosis: Newborn male delivered in the hospital by cesarean section and with Down syndrome (Trisomy 21)
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