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10E0XZZ
Objectives
• Identify basics of obstetric delivery
procedure coding
• Understand which procedures are coded
in Obstetrics section in PCS
• Ability to assign correctly delivery and
lacerations obstetrical procedures
Products of Conception
(POC)
• The only procedures that are coded in the OB section
are done on products of conception. First character 1
• Products on conception include
 Fetus/embryo
 Aminotic fluid
 Fetal blood
 Retained products of conception
 Endometrium following abortion or delivery
 Umbilical cord
 Placenta
Determine if it is a product of
conception
 Simply if the body part belongs to the
female patient when she is not
pregnant, the body part is not a product
of conception, and it should be coded in
the Medical and Surgical Section
 Examples:
OB lac repair, BTL, cerclage of the cervix
Root Operations unique to
OB
• Abortion: definition- artificially terminating a
pregnancy
• Delivery: definition- assisting the passage of
products of conception from the genital canal
Offical Coding
Guidelines
C1. Procedures performed on the POC are coded to the OB section.
Procedures performed on the pregnant female other than POC are
coded to the appropriate root operation in the Medical & Surgical
section
C2. Procedures performed following a delivery or abortion for
curettage of the endometrium or evacuation of retained POC are all
coded in the OB section, to the root operation Extraction and the body
part POC, retained. Diagnostic or the therapeutic dilation and
curettage performed during times other than the postpartum or postabortion period are coded in the Medical & Surgical section to the root
operation Extraction and the body part Endometrium.
Delivery of fetus
PCS defines delivery of the fetus into two sections of the
OB section
 Can be viable fetus or nonviable POC
 Extraction: pulling or stripping out or off a portion of body
part the use of force
• 3rd character D
• Includes: c-sections, forceps and internal version
 Delivery: assisting the passage of POC from the genital
canal
• 3rd character is E
• Always an external approach
• No device or qualifier
C-section
Build a code-
1 Obstetrics
0 Pregnancy
D Extraction
0 Open
Z No device
? 0- classical
1- low cervical
Forceps
Forceps design
Two are two crossing branches
Each branch has 4 parts
• Blade
• Shank
• Lock
• Handle
Each blade has two curves
• One corresponds to the rounded
head of the fetus
• Second one corresponds to the
upward pelvic curve and the axis
of the birth canal
• Some blades have openings
(fenestrated) or depressions
(pseudofenstrated)
• The blade modifications allow for
firmer grasp of the fetal head
Fetal station
Fetal station is the relationship between the
presenting part of the fetus body (head,
shoulder, buttock or feet) and two parts of the
mother called the ischical spine
Fetal Station
•
•
•
•
•
•
Above the ischial spine
It is reported with -1 to -5
Each number is approximately 1 cm
Below the ischial spine
It is reported with +1 to +5
Each number is approximately 1 cm
Vacuum Extraction
• Vacuum extraction is
Qualifier or 7th character of
6
• Code assign of delivery
with vacuum extraction
10D07Z6
• Vacuum assisted Csection
• Coding Clinic 4th
quarter 2014 pg 43
• Vacuum extraction to
assist during c-section
is include and no code
seperately
Abortion
• 3rd character A
• Only applies to artificially terminated
pregnancies
• Subdivided into device used or no Device
 Laminaria
 Abortifacient
 Vacuum
 Mechanical
Abortion PCS table
Episiotomy
• 0W8NXZZ- see the division of the
perineum female
• Not a product of conception; so the codes
are located in the Medical & Surgical
section
• If the episiotomy extends to include a
laceration, code both the episiotomy and
the repair of the laceration
Female Anatomy
Lacerations
1st degree tears- involve damage to the
fourchette, vaginal mucosa and the underlying
muscle are exposed but not torn
2nd degree tears- include the posterior vaginal
walls and perineal muscles, but the anal
sphincter is intact
3rd degree tears- extend to the anal sphincter,
but the rectal mucosa is intact
4th degree tears- involve the rectal and anal
mucosa
Muscle layers in OB
lacerations
B 3.5 states if a muscle layer is performed
and it involves overlapping layers code to the
deepest level
OB lacerations do not involve products of
conception so should be coded in the Medical &
Surgical section
3rd and 4th degree laceration repairs, currently, will
change the DRG to a surgical DRG
Lacerations
CC, 4th quarter 2013, pg 120, “… In ICD-10-PCS and
‘Open Approach” is defined as cutting through the
skin or mucous membrane and any other body layers
necessary to expose the site of the procedures. In this
case, “open approach: is assigned because the
laceration has cut through the external body layers
exposing the muscle (ie the site of the procedure)
Although the laceration occurred spontaneously, it is
nevertheless the means by which the procedure site
is exposed.”
Clitoral laceration
 CC, 4th quarter 2014, pg 120-121, if the
laceration includes only the clitoris the code
would be 0UQJXXZZ,
Female vulva includes these structures: mons
pubis, labia major, labia minora, clitoris,
vestibule of the vagina, greater and lesser
vestibular glands, vaginal orifice
Use the body structure vulva if the laceration
includes other lacerations of the above
structures.
Thank you