ICD-10-CM Cding Basics Chapter Specifics Chapter 15 Pregnancy, Childbirth and the Puerperium Vilma Smith, LVN, CPC, CCS Debra Bales, LVN, CPC Jnay Rischer, CPC 1 Rev. May 2015
ICD-10-CM Cnventins General rules fr use f the classificatin independent f the guidelines Cnventins and instructins f the classificatin takes precedence ver guidelines Incrprated within the Alphabetic Index and Tabular list as instructinal ntes 2
Chapter 15: Pregnancy, Childbirth and the Puerperium (O00-O9A) Cding requirements Only used n the maternal recrd Sequencing pririty ver ther chapter cdes Reprt additinal cdes frm ther chapters t further specify the cnditin If pregnancy is incidental t the encunter, use cde Z33.1, Pregnant state, incidental It is the prvider s respnsibility t state that the cnditin being treated is nt affecting the pregnancy Cding the trimester and the weeks f gestatin are vital t the maternal recrd Majrity f cdes have a final character indicating trimester f pregnancy Trimester r number f weeks shuld be based n the prvider s dcumentatin Gestatin cdes are fund in Categry Z3A.- Indicates the weeks f gestatin f the pregnancy 3
Chapter 15: (cnt.) Timeframes fr the trimesters r number f weeks shuld be based n the dcumentatin n the OB frm First Trimester - Less than 14 weeks 0 days Secnd Trimester - 14 weeks 0 days t less than 28 weeks 0 days Third Trimester - 28 weeks 0 days t delivery Nt every single cde in Chapter 15 has a trimester cmpnent Sme cnditins always ccurs in a specific trimester Cncept f trimester is nt applicable t the cnditin Categry Z37.- cde is assigned fr utcme f delivery n every maternal delivery recrd D nt use in subsequent recrds r n the newbrn recrd 4
Chapter 15: (cnt.) Cmplicatins f Pregnancy Certain categries distinguish between cnditins f the mther that existed prir t pregnancy (pre-existing) and thse that are a direct result f pregnancy (O10-O16) Imprtant t assess whether a cnditin was pre-existing r develped during r due t the pregnancy t assign the crrect cde Pre-existing hypertensin in pregnancy (O10.-) Pre-existing hypertensive heart disease cmplicating pregnancy (O10.1-) It is necessary t use an additinal cde t identify the type f Hypertensive heart disease (I11.-) Pre-existing hypertensive chrnic kidney disease cmplicating pregnancy (O10.2-) Use an additinal cde t identify the type f hypertensive chrnic kidney disease (I12.-) Pre-existing hypertensive heart and chrnic kidney disease cmplicating pregnancy (O10.3-) Use an additinal cde t identify the type f hypertensive heart and chrnic kidney disease (I13.-) Pre-existing secndary hypertensin cmplicating pregnancy (I10.4-) Pre-existing hypertensin with pre-eclampsia (O11.-) Use an additinal cde frm I10 t identify the type f HTN 5
Chapter 15: (cnt.) Gestatinal [Pregnancy-induced] edema and prteinuria withut HTN (O12.-) Gestatinal edema (O12.0-) Gestatinal prteinuria (O12.1) Gestatinal edema with prteinuria (O12.2-) Gestatinal [Pregnancy-induced] Hypertensin withut significant prteinuria (O13.-) Pre-eclampsia Mild-mderate pre-eclampsia (O14.0-) Severe pre-eclampsia (014.1-) HELLP Syndrme (O14.2) Severe pre-eclampsia with hemlysis, elevated liver enzymes and lw platelet cunt Eclampsia Eclampsia in pregnancy (O15.0-) Eclampsia in labr (O15.1) Eclampsia in the puerperium (O15.2) 6
Chapter 15: (cnt.) Other maternal disrders predminantly related t pregnancy (O20-O29) Hemrrhage in early pregnancy (Hemrrhage befre cmpletin f 20 weeks) Threatened Abrtin (O20.0) Other hemrrhage in early pregnancy (O20.8) Excessive vmiting in pregnancy Mild hyperemesis gravidarum (O21.0) Hyperemesis gravidarum with metablic disturbance (O21.1) Late vmiting f pregnancy (O21.2) Varicse veins f lwer extremity in pregnancy (O22.0-) Genital varices in pregnancy (O22.1-) Hemrrhids in pregnancy (O22.4-) 7
Chapter 15: (cnt.) Infectins f geniturinary tract in pregnancy Use additinal cde t identify rganism (B95.-, B96.-) Infectins f kidney in pregnancy (O23.0-) Includes pyelnephritis in pregnancy Infectins f bladder in pregnancy (O23.1-) Infectins f urethra in pregnancy (O23.2-) Infectins f the genital tract in pregnancy Use additinal cde t identify rganism (B95.-, B96.-) Infectin f cervix in pregnancy(o23.51-) Salping-phritis in pregnancy(o23.52-) 8
Chapter 15: (cnt.) Diabetes Mellitus in pregnancy, childbirth, and the puerperium Pre-existing diabetes mellitus type 1 in pregnancy, childbirth and the puerperium (O24.0-) Use additinal cde (E10.-) t further identify any manifestatins Pre-existing diabetes mellitus, type 1 in pregnancy (O24.01-) Pre-existing diabetes mellitus, type 1 in childbirth(o24.02) Pre-existing diabetes mellitus, type 1 in the puerperium (O24.03) Pre-existing diabetes mellitus, type 2 in pregnancy, childbirth and the puerperium Use additinal cde (E11.-) t further identify any manifestatins Use additinal cde if applicable. Lng term (current) use f insulin (Z79.4) 9
Chapter 15: (cnt.) Pre-existing diabetes mellitus, type 2, in pregnancy, childbirth and the puerperium Pre-existing diabetes mellitus, type 2 in pregnancy (O24.11-) Pre-existing diabetes mellitus, type 2 in childbirth (O24.12) Pre-existing diabetes mellitus, type 2 in the puerperium (O24.13) Gestatinal Diabetes Mellitus N additinal cde shuld be used with cdes frm subcategry O24.4 Gestatinal diabetes mellitus in pregnancy (O24.41-) Dcument diet cntrlled insulin cntrlled Gestatinal diabetes mellitus in childbirth (O24.42-) Dcument diet cntrlled insulin cntrlled Gestatinal diabetes mellitus in the puerperium (O24.43-) Dcument diet cntrlled insulin cntrlled 10
Chapter 15: (cnt.) Alchl use cmplicating pregnancy, childbirth and the puerperium (O99.31-) Use additinal cde(s) frm F10.- Alchl related disrders, t identify manifestatins f the alchl use Review guidelines t determine bld alchl level, if necessary (Y90.-) Drug use cmplicating pregnancy, childbirth, and the puerperium (O99.32-) Reprt additinal cde(s) frm F11-F16 and F18-F19 t identify manifestatins f the drug use Smking (tbacc) cmplicating pregnancy, childbirth and the puerperium (099.33-) Reprt additinal cde frm F17 t identify type f tbacc 11
Chapter 15: (cnt.) Fr rutine utpatient prenatal visits, withut cmplicatins, use cdes frm categry Z34, Encunter fr supervisin f nrmal pregnancy These cdes shuld nt be used in cnjunctin with chapter 15 cdes Fr rutine prenatal utpatient visits fr high-risk patients, reprt cde O09, Supervisin f high risk pregnancy Nrmal Delivery Secndary Chapter 15 cdes may be used in cnjunctin with these cdes Cde O80 shuld be assigned fr delivery f a full-term, nrmal, single, healthy infant withut cmplicatins antepartum, during delivery, r pstpartum during delivery D nt use cde O80 if anther cde frm chapter 15 is necessary t describe a current cmplicatin f the antenatal, delivery, r perinatal perid Cdes frm ther chapters may be used with cde O80 if they are nt related t r cmplicating the pregnancy 12
Chapter 15: (cnt.) Obstetrics 7 th Characters: Categry / Cdes O31.-; O32.-; O33.3-O33.6; O35.-; O36.-; O40.-; O41.-; O60.1-; O60.2-; O64.- and O69.- requires a 7 th character cde Assigning the 7 th character where applicable t identify the fetus fr which the cmplicatin cde applies 0 nt applicable r unspecified Single gestatin, insufficient dcumentatin, r cannt be clinically determined 1 Fetus 1 2 Fetus 2 3 Fetus 3 4 Fetus 4 5 Fetus 5 9 ther Fetus 13