Download Advanced ICD-10-CM/PCS Coding for OB/Pregnancy Plan for Today

10/13/2014
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
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10/13/2014
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,
2014. 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 2014.
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.
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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.
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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 O34.4causing obstructed labor O65.5
Placeholder Character - X
• The 7th character is required for some
codes.
• No 7th character = invalid code
• What happens if the code does not have 6
characters and a 7th 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 7th
character is in the 7th position.
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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
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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.
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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
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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.
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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
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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
– O24.311 Unspecified pre-existing diabetes mellitus
in pregnancy, first trimester
– O24.312 Unspecified pre-existing diabetes mellitus
in pregnancy, second trimester
– O24.313 Unspecified pre-existing diabetes mellitus
in pregnancy, third trimester
– O24.319 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
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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 O60.1. 7th 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
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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 O30.00conjoined O30.02dichorionic/diamniotic(two placenta, two amniotic
sacs) O30.04monochorionic/diamniotic(one placenta, two amniotic
sacs) O30.03monochorionic/monoamniotic(one placenta, one
amniotic sac) O30.01unable to determine number of placenta and number of
amniotic sacs O30.09unspecified number of placenta and unspecified number
of amniotic sacs O30.0022
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Tabular Entry
• O30.011 Twin pregnancy,
monochorionic/monoamniotic, first trimester
• O30.012 Twin pregnancy,
monochorionic/monoamniotic, second trimester
• O30.013 Twin pregnancy,
monochorionic/monoamniotic, third trimester
• O30.019 Twin pregnancy,
monochorionic/monoamniotic unspecified
trimester
• Codes to be reported for diagnosis of twin
pregnancy, monochorionic/monoamniotic at 20
weeks gestation O30.012, Z3A.20
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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
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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 7th 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
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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
1
2
3
4
5
6
7
Section
Body
System
Device
Root
Operation
Body Part
Approach
Qualifier
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10/13/2014
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
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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: 73.59
– 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
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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.
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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 2nd
degree tear but specific site not identified?
– Vaginal Wall = 0UQG0ZZ (Female Reproductive system)
– Perineal Muscle = 0KQM0ZZ (Muscle body system)
– Pelvic floor= repair perineum 0WQN0ZZ
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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 4th
degree tear but specific site not identified?
– Rectum= 0DQP0ZZ
– Anus = 0DQQ0ZZ
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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
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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
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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
– O09.612 Young primigravida, second trimester
– Z3A.16 16 weeks gestation
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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?
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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
O09.513 38 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
– O91.22
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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
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Resources
• http://journal.ahima.org/2014/03/31/se
nate-votes-on-icd-10-delay-bill/
• http://www.gchc.org/wpcontent/uploads/2011/10/11-3-11-ICD10-Cincinnati_FINAL-Leon-Chisen.pdf
• Barta, Ann. "Obstetric Coding in ICD-10CM/PCS." Journal of AHIMA 81, no.6
(June 2010): 68-70.
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