Chapters 15

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• Chapters 15 16 Guidelines Introduction
  Module 18
• Reimbursement Management Consultants

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Obstetrics and Newborn Coding in ICD-10 CM/PCS-An
Introduction

• Laura Legg, RHIT, CCS
• AHIMA approved ICD-10 Trainer

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Reimbursement Management Consultants

• About the presenter Ms. Legg has 30 years
  experience as a consultant, coder and auditor at
  several acute care hospitals, critical access
  hospitals and major health systems. She has also
  developed education presentations in the areas of
  physician queries, sepsis coding and ICD-10
  planning implementation. Ms. Legg is a coding
  consultant for Reimbursement Management
  Consultants.

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Disclaimer

• The information in this presentation, whether
  oral or contained in written materials, is
  provided for general guidance and is just being
  offered as general information to the attendees.
• RMC, Inc. specifically disclaims any implied
  guarantee of usage of information any specific
  purpose. RMC, Inc. will have no liability or
  responsibility to any person or entity with
  respect to any loss or damage caused by the use
  of the information from this presentation.
• The information provided is not a substitution or
  a replacement for any compliance advise,
  consultation, or service. Consultation with a
  professional in the respective area of concern is
  highly suggested.

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Disclaimer (Cont.)

• Therefore, let it be known the information is
  provided as is without warranties of any kind,
  expressed or implied, including accuracy,
  timeliness, and completeness.
• Please note the presentation has been designed to
  include accurate, concise, comprehensive, and
  complete information.
• Please remember it is not to be used to take the
  place of other professional or legal advice.

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PRESENTATION IS BASED ON PRESENTER'S
INTERPRETATION OF THE ICD-10-CM CODING
GUIDELINES. CONCENTRATING ON THE PRINCIPLES

• About Today's Workshop

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Objectives for todays presentation

• Review ICD-10-CM/PCS Coding Guidelines for
  Obstetric and Newborn Coding
• Identify differences between ICD-9-CM and
  ICD-10-CM/PCS for Obstetrics coding
• Discuss root operations for obstetrics
• Accurately assign codes to pregnancy, childbirth,
  and puerperium case scenarios including PCS
  coding

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ICD-10 CM 2012 Official Coding Guidelines

• Chapter 15-Pregnancy, Childbirth and the
  Puerperium guidelines
• Chapter 16-Certain Conditions Originating in the
  Perinatal Period guidelines
• https//www.cms.gov/Medicare/Coding/ICD10/Download
  s/2012_ICD10_Guidelines.pdf

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Organization of Chapter 15
Section Section Title
O00-O08 Pregnancy with abortive outcome
O09 Supervision of high risk pregnancy
O10-O16 Edema, proteinuria, and hypertensive disorders in pregnancy, childbirth and the puerperium
O20-O29 Other maternal disorders predominantly related to pregnancy
O30-O48 Maternal care related to the fetus and amniotic cavity and possible delivery problems
O60-O77 Complication of labor and delivery
O80-O82 Encounter for delivery
O85-O92 Complications predominantly related to the puerperium
O94-O9A Other obstetric conditions, no elsewhere classified
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General rules for obstetric cases

• Chapter 15 have sequencing priority over codes
  from other chapters
• Additional codes may be used in conjunction with
  chapter 15 codes to further specify conditions

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New Diagnosis Coding Guidelines we will cover

• Final character for trimester
• 7th character for fetus identification
• Weeks of gestation
• Timeframe changes
• Terminology changes
• Code title changes

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Final character for trimester

• The episode of care is no longer the axis of
  classification but rather the trimester in which
  the condition occurred
• Trimesters defined
• 1st trimester less than 14 weeks
• 2nd trimester 14 weeks to 28 weeks
• 3rd trimester 28 weeks until delivery

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Final character for trimester

• The final character in the code will indicate the
  trimester
• Antepartum, postpartum and whether a deliver has
  occurred are not used.
• Final character assignment should be based on
  providers documentation
• in childbirth should be chosen whenever
  delivery occurs during the current admission

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Unspecified trimester

• There is a code for unspecified trimester but it
  should be rarely used and only when the coder is
  unable to obtain clarification

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7th Character Extension

• Seventh character extension is required to
  identify the fetus in a multiple gestation
• 0 not applicable or unspecified
• 1 fetus 1
• 2 fetus 2
• 3 fetus 3
• 4 fetus 4
• 5 fetus 5
• 9 other fetus

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New 7th character for fetus identification

• Assign a 7th character for certain categories to
  identify the fetus for which the complication
  applies
• Assign 0 for
• Single gestations
• When documentation is insufficient to determine
  the fetus affected and it cannot be clarified
• When it is not possible clinically to know which
  fetus is affected

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Weeks of Gestation code

• The weeks of gestation codes from category Z3A
  should be reported on maternal records to
  indicate the weeks of gestation of the pregnancy.

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Time Frame changes for ICD-10-CM

• The time frame for differentiating the abortion
  and fetal death codes has been changed from 22 to
  20 weeks
• The time frame for differentiating early and late
  vomiting in pregnancy has been changed from 22 to
  20 weeks
• Preterm labor is defined as before 37 weeks of
  gestation

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Terminology change

• ICD 9 CM used the term Late Effect
• ICD 10 CM uses the term Sequelae-something that
  follows or comes after
• Example
• -ICD-9 CM title Code 677, late effect of
  complication of pregnancy
• -ICD-10 CM title Code O94, sequelae of
  complication pregnancy, childbirth and the
  puerperium

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Code Title changes

• ICD-9-CM 654, Abnormality of organs and soft
  tissue of the pelvis
• ICD-10-CM O34, Maternal care for abnormality of
  pelvic organs

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Mothers Chart

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Incidental pregnancy

• Should the provider document that the pregnancy
  is incidental to the encounter assign code Z33.1,
  pregnant state incidental
• Remember it is the providers responsibility to
  state that the condition being treated is not
  affecting the pregnancy
• ICD -9 V22.2 incidental pregnancy
• ICD-10 CM Z33.1, pregnant state, incidental

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Elective Abortion

• Codes for elective abortion (legal or
  therapeutic) are classified in the abortion codes
  in ICD-9-CM
• Elective abortion has been moved to code Z33.2,
  Encounter for elective termination of pregnancy,
  Chapter 21
• Complications of induced termination of pregnancy
  are found in category O04

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Obstruction of Labor

• In ICD-10-CM codes for obstructed labor
  incorporate the reason for the obstruction into
  the code, so only one code is required.
• ICD-9-CM obstructed labor due to face
  presentation required both code 660.0 and coder
  652.4
• ICD-10-CM will only require a code from
  subcategory, O64.2, obstructed labor due to face
  presentation

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Prenatal outpatient visits for high risk patients

• Routine visit for a high risk pregnancy is coded
  from category O09, supervision of high risk
  pregnancy
• ICD-9 V23
• ICD-10 O09

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Admission for routine postpartum care

• When the mother delivers outside the hospital
  prior to admission and is admitted for routine
  postpartum with no complications code Z39.0
  encounter for care and examination of mother
  immediately after delivery is assigned as the
  principal diagnosis.
• ICD-9 CM V24.0
• ICD-10 CM Z39.0

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Abuse in a pregnant patient

• Subcategory O9A.3 physical abuse complication
  pregnancy, childbirth and the puerperium
• 09A.4 sexual abuse complication pregnancy,
  childbirth and the puerperium
• O9A.5-psychological abuse

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Selection of OB principal or first-listed
diagnosis

• Routine outpatient prenatal visits where no
  complications occur are coded to category Z34,
  encounter for supervision of a normal pregnancy
• ICD-9 V22.0 Supervision of normal 1st
  pregnancy and V22.1 supervision other
  normal pregnancy
• ICD 10 Z34

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Normal Delivery-Moms chart

• Normal Delivery without complications
• ICD-9-CM 650-Normal Delivery V27.0 Outcome of
  delivery
• ICD-10-CM O80-Encounter full term,
  uncomplicated delivery
• Z3A40-40 weeks gestation of pregnancy
• Z370-Single live birth

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Outcome of Delivery code

• ICD-10 CM a code from category Z37, outcome of
  delivery should be included in the maternal
  record when delivery has occurred
• ICD-9 V27.0-V27.9 Outcome of Delivery
• ICD-10 Z37 Outcome of Delivery

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ICD-10-PCS

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PCS Guidelines

• There are written guidelines for ICD-10 PCS
• Coders must learn them to accurately assign PCS
  codes!
• See reference slide

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ICD-10 PCS Code structure

• 16 sections
• Seven character alphanumeric codes
• Each character contains up to 34 possible values
• Each value represents a specific option for the
  general character definition
• 10 digits (0-9)
• 24 letters A-H, J-N, P-Z. No letter O or I

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Anatomy of a PCS code
Character 1 Section Character 2 Body System Character 3 Root Operation Character 4 Body part Character 5 Approach Character 6 Device Character 7 Qualifier
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What about ICD-10 PCS?

• The obstetric section of ICD-10-PCS (section 2)
  includes procedures on the products of conception
  only.
• Procedures done on the pregnant female (e.g.
  episiotomy) are coded in the medical and surgical
  section
• The letters O and I are
• not used in PCS!

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Products of Conception

• Refers to all physical components of a pregnancy
  including
• The fetus
• Amnion
• Umbilical cord
• Placenta

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Obstetrics section PCS code structure
Character Value
1. Section-general type of procedure 1-Obstetrics
2. Body system-anatomic region 0-Pregnancy
3. Root operation-objective of the procedure There are 12 root operations for this section which we will review in the next slide.
4. Body Part-specific anatomic site where the procedure is performed 0-products of conception 1-products of conception, retained 2-products of conception, ectopic
5. Approach the technique the physician used to reach the site There are 7 approaches involved in the obstetrics section
6. Device-The material or appliance that remains in or on the body at the end of the procedure 3-Monitoring electrode Y-Other device Z-No device
7. Qualifier-value specific to the root operation to specify the type of extraction, type of fluid taken out etc.. There are 34 values for the qualifier character
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Root operation Delivery
1 Obstetrics 0 Pregnancy E Delivery-Assisting the passage of the products of conception from the genital canal 1 Obstetrics 0 Pregnancy E Delivery-Assisting the passage of the products of conception from the genital canal 1 Obstetrics 0 Pregnancy E Delivery-Assisting the passage of the products of conception from the genital canal 1 Obstetrics 0 Pregnancy E Delivery-Assisting the passage of the products of conception from the genital canal
Body part Character 4 Approach Character 5 Device Character 6 Qualifier Character 7
0 Products of conception X External Z no device Z no qualifier
10E0XZZ code for Delivery, products of conception 10E0XZZ code for Delivery, products of conception 10E0XZZ code for Delivery, products of conception 10E0XZZ code for Delivery, products of conception
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Facts about root operations

• 3rd character of a PCS codes identifies the root
  operation
• Root operation-objective of the procedure being
  performed
• Coding guidelineA-11- physician is not expected
  to use the terms in PCS code descriptions nor is
  the coder required to query when correlation is
  clear
• Coder can independently correlate assignment of
  the root operation

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Root Operations in the OB section

• Abortion-Artificially terminating a pregnancy
• Change-Taking out or off a device from a body
  part and putting back an identical or similar
  device in or on the same body part without
  cutting or puncturing the skin or mucous
  membrane. All change procedures code to operative
  value 5 to indicate External.

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Root Operations

• Delivery-Manually-assisted vaginal delivery,
  assisting the passage of the products of
  conception from the genital canal
• Drainage-Taking or letting out fluids and/or
  gases from a body part (amniocentesis)
• Extraction-Pulling or stripping out or off all or
  a portion of a body part by the use of force
  (laparoscopic removal of an ectopic pregnancy)

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Root Operations

• Insertion-Putting in a nonbiologic substance that
  monitors, assists, performs, or prevents a
  physiological function but does not physically
  take the place of a body part (fetal pulse
  oximetry)
• Inspection-Visually and/or manually exploring a
  body part, with or without optical
  instrumentation.

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Root Operations

• Removal-Taking out or off a device from a body
  part.
• Repair-Restoring, to the extent possible, a body
  part to its normal anatomic structure and
  function. Repair functions as a NEC option.
• Reposition-Moving to its normal location or other
  suitable location all or a portion of a body part.

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Root Operations

• Resection-Cutting out or off, without
  replacement, all of a body part, e.g. total
  excision of right fallopian tube pregnancy.
• Transplantation-Putting in all or a portion of
  living body part taken from another individual or
  animal to physically take the place and/or
  function of all or a portion of a similar body
  part. e.g. Laparoscopic fetal kidney transplant.

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Steps of coding using ICD-10-PCS
1. You will use the Alphabetic index to access the multiple root operation tables. There you will find the values needed to construct a 7 character ICD-10-PCS code.
Look up the main term in the alphabetic index. They are set in boldface and are in alphabetical order
2. Indented below the main term you can locate subterms.
4. The ICD-10 PCS alphabetic index provides the first 3-4 characters of the code, with the first 3 characters indicating the correct operation table to reference
5. The values for characters 1-3 are located at the top of each root operation table.
5. The table also contains four columns and a number of rows.
Lets try one Look up Cesarean section Cesarean section see extraction, products of conception 10D0 Go the 10D root operation table and review the operative report to obtain the information needed to assign the remaining characters to the code
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Cesarean section-10D00Z1
ICD-10-PCS code character Value Assigned for Cesarean section
Section 1 Obstetrics
Body System 0 Pregnancy
Operation D Extraction
Body Part 0 Products of conception
Approach 0 Open
Device Z No device
Qualifier 1. Low cervical
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Perineal lacerations

• Perineal lacerations are classified as first,
  second, third or fourth degree

Degree of laceration Definitions-taken from Faye Browns ICD-9 CM Coding Handbook 2012
First degree tear Tear involves damage to the fourchette and vaginal mucosa and underlying muscles are exposed but not torn
Second degree Tear includes the posterior vaginal walls and perennial muscles, but the anal sphincter is intact
Third degree Tears extend to the anal sphincter, but the rectal mucosa is intact
Fourth degree Tears involve the rectal and anal mucosa
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Female anatomy

• Fourchette-The fold of skin that forms the
  posterior margin of the vulva
• Vulva-the external genital organs of the female
• Perineum-The perineum is the region of the body
  inferior to the pelvic diaphragm and between the
  legs.
• Perennial muscles-Muscles of the perineum, i.e.
  Kegles exercises.

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1st degree OB laceration repair

• 1st degree involves fourchette, superficial
  perineal skin and vaginal mucosa
• Root operation Repair-restoring to the extent
  possible, a body part to its normal anatomic
  structure and function
• Repair, skin, perineum
• 0HQ9XZZ

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0HQ9XZZ-Repair 1st degree OB laceration

• 0Medical and Surgical
• H-Skin and Breast
• Q-Repair
• 9-Skin, Perineum
• X-External
• Z-no device
• Z-no qualifier

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2nd degree OB laceration repair-0KQM0ZZ

• 2nd degree extends to the perineal muscles and
  fascia
• 0KQM0ZZ

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0KQM0ZZ

• 0-Medical and surgical
• K-muscles
• Q-repair
• M-perineum muscle
• 0-open
• Z-no device
• Z-no qualifier

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3rd degree OB laceration repair

• 3rd degree extends to the anal sphincter
• Repair
• Anal sphincter
• 0DQR0ZZ

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0DQR0ZZ

• 0-Medical and Surgical
• D-Gastrointestinal System
• Q-Repair
• R-Anal sphincter
• 0-Open
• Z-no device
• Z-no qualifier

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4th degree OB laceration repair

• 4th degree extends to the rectal mucosa
• Repair
• Rectum
• 0DQP0ZZ

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0DQP0ZZ

• 0-Medical and Surgical
• D-Gastrointestinal
• Q-Repair
• P-Rectum
• 0-Open
• Z-No device
• Z-No qualifier

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Forceps operation with episiotomy

• ICD-9
• 72.1 Low forceps operation with episiotomy
• ICD-10
• 0W8NXZZ division of female perineum, external
  approach
• 10D07Z3 extraction of products of conception, low
  forceps, via natural or artificial opening

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Episiotomy

• O-Med Surg
• W-Body system, Skin
• 8-Root operation Division
• N-body part-Perineum
• X-Approach-External
• Z-No device
• Z-No qualifier

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Low forceps delivery

• 1-Obstetrics section
• 0-body system
• D-root operation, extraction
• 0-body part, product
• 7-Approach, via natural or artificial opening
• Z-no device
• 3-Qualifier, low forceps

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Lets Practice

• What are the correct codes for a 39-year-old
  woman who is 26 weeks pregnant and being seen for
  gestational hypertension?
• ICD-10-CM codes are
• O13.2 Gestational pregnancy induced hypertension
  without significant proteinuria, 2nd trimester
• O09.522, 26 weeks gestation of pregnancy
• Z3A.26 Supervision of elderly multigravida second
  trimester

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Abortive Outcome

• 23-year-old gravid 1, para 1, female has
  spotting, cramping and bleeding. She has an
  incomplete early spontaneous abortion at 12 weeks
  and is taken to surgery for DC. Her stay is
  complicated by a UTI due to E-coli.
• Which codes would you use?

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Answer

• O03.38 abortion complicated by urinary tract
  infection
• B96.2 E-coli
• 10D17ZZ-extraction, Products of conception,
  retained

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Lets practice

• This is a 28-year-old patient with a history of
  previous Cesarean section here for delivery due
  to fetal distress. She is 39 weeks and wants a
  VBAC. During delivery she is overcome with
  fatigue and mid forceps are used over a midline
  episiotomy. A single live born female is
  delivered.

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Delivery with mid forceps and episiotomy

• O75.81 Pregnancy, complicated by fatigue, during
  labor and delivery
• O43.21 Delivery, vaginal following previous
  cesarean delivery
• Z37.0 Outcome of Delivery, single liveborn
• 10D07Z4 extraction products of conception, mid
  forceps
• 0W8NXZZ-division, perineum, female

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Obstetrical forceps

• Low forceps-Babys head is on the pelvic floor
• Mid forceps-head is midplane of the mothers
  pelvis.
• High forceps-head is not engaged in the birth
  canal. No longer acceptable or meeting the
  standard of care.

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Procedures in Obstetrics Section

• 10A07Z6-root operation abortion
• Abortion, Vacuum
• 10E0XZZ-root operation delivery Delivery,
  manually assisted
• 10D17ZZ-root operation extraction by body
  part, products of conception retained
• Manual extraction of placenta

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Case to Code

• This 23-year-old patient came in to deliver at 40
  weeks. During labor fetal heart rate abnormality
  was noted. She was Group B positive.
  Spontaneous vaginal delivery was done after AROM.
  No perineal lacerations were noted.

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Mapping example

• ICD-9-CM
• 659.71 Abnormality in fetal heart rate, delivered
• 648.91 Other Current condition, Mom complicating
  preg, del
• V02.51 Carrier/Suspected carrier of infectious
  diseases, other
• V27.0 Outcome of delivery
• ICD-10-CM
• O76 Abnormality in fetal heart rate and rhythm
  complicating labor and delivery
• 648.91 Unable to map (malnutrition in childbirth
  and O99.284 endocrine, nutritional and metabolic
  diseases complicating childbirth)
• Z22.330 Carrier of Group B streptococcus
• Z3A.40- 40 weeks of gestation
• Z37.0 Single live birth

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Newborn chart

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Newborn coding in ICD-10 CM

• Changed from Chapter 15 to Chapter 16
• Perinatal period is still defined as before birth
  through the 28th day following birth.

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Organization of Chapter 16
P00-P04 Newborn affected by maternal factors and by complications of pregnancy, labor and delivery
P05-P08 Disorders related to length of gestation and fetal growth
P09 Abnormal findings on neonatal screening
P10-P15 Birth trauma
P19-P29 Respiratory and cardiovascular disorders specific to the perinatal period
P35-P39 Infections specific to the perinatal period
P50-P61 Hemorrhagic and hematological disorders of newborn
P70-P74 Transitory endocrine and metabolic disorders specific to newborn
P76-P78 Digestive system disorders of newborn
P80-P83 Conditions involving the integument and temperature regulation of newborn
P84 Other problems with newborn
P90-P96 Other disorders originating in the perinatal period
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Coding Guidelines for Chapter 16

• General rules
• Principal diagnosis for the birth record
• Use of Chapter 16 codes with other codes
• Code all clinical significant conditions
• Suspected conditions not found
• Coding for birth weight and gestational age

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General Perinatal Rules

• Never for use on the maternal record
• Principal diagnosis for birth record
• ICD-10 CM category Z38, liveborn infant
• ICD-9 CM V30-V39
• Still assigned only once

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Chapter 16 codes use with other codes

• Codes from chapters may be used for more specific
  detail
• Signs and symptoms used if no established
  diagnosis
• For perinatal conditions the chapter 16 code
  should be sequenced first

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Code all clinically significant conditions

• A condition is clinically significant if it
  requires
• Clinical evaluation
• Therapeutic treatment
• Diagnostic procedures
• Extended length of stay
• Increased nursing care and/or monitoring
• Has implication for future health care needs

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Additional diagnoses

• Continue to code conditions that require
  treatment or further investigation, prolong the
  length of stay or require resource utilization
• Continue to assign codes for conditions specified
  as having implications for further health care
  needs

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Code Birth weight and gestational age

• When both birth weight and gestational age of the
  newborn are available both should be coded with
  birth weight sequenced before gestational age

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Evaluation of suspected conditions

• ICD-9-CM Category V29
• ICD-10-CM Categories P00 to P04
• Used when a healthy newborn is evaluated
• Not used when signs or symptoms are present

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Prematurity and fetal growth retardations

• Category P05, disorders of newborn related to
  slow fetal growth and fetal malnutrition
• Category P07 disorders of newborn related to
  short gestation and low birth weight
• -Based on the recorded birth weight and estimated
  gestational age

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Bacterial Sepsis of Newborn

• ICD-10 CM Category P36, bacterial sepsis of
  newborn
• ICD-9 CM 771.81 Sepsis of newborn
• Should assign secondary code for causal organism

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Stillbirth

• Code P95, Stillbirth is only for use in
  facilities where separate records for stillbirths
  are maintained.
• No other code should be used with P95
• P95 should not be used on the mothers record

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Common NB Chart

• Newborn with circumcision
• ICD-9-CM
• V30.00 Single liveborn, born in hospital
• 64.0 Circumcision
• ICD-10-CM PCS
• Z38.00 Single liveborn infant, delivered
  vaginally
• Birth weight
• Gestational age
• 0VTTXZZ Resection of Prepuce, External approach

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laural_at_rmcinc.org

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References

• https//www.cms.gov/Medicare/Coding/ICD10/Download
  s/ICD10SmallHospitalHandbook.pdf
• The Coders Guide to ICD-10, HC Pro, 2011,
  McCall, Shannon RHIA, CCS, CCS-P, CPC, CPC-1,
  CEMC,CCDS Jennifer Avery, CCS, CPC-H, CPC,
  CPC-1
• https//www.cms.gov/Medicare/Coding/ICD10/Download
  s/2012_ICD10_Guidelines.pdf
• http//www.cdc.gov/nchs/icd/icd10cm.htm
• http//www.cms.gov/Medicare/coding/ICD10/downloads
  /PCS2012guidelines.pdf

87

• Keep Calm
• and
• Carry On