News
ICD-10-CM documentation and coding for GYN procedures
With the new coding set in our sights, here’s a line-up of key changes that will affect final reimbursements
Additional definitions that may impact coding:
- preterm labor or delivery: 20 completed weeks to less than 37 completed weeks
- full-term labor or delivery: 37 completed weeks to 40 completed weeks
- postterm pregnancy: more than 40 completed weeks to 42 completed weeks
- prolonged pregnancy: more than 42 completed weeks.
You also will be required to include a code for gestational age any time you report an obstetric complication. This and the trimester information will change as the pregnancy advances, so always be sure that the code selected matches the gestational age on the flow sheet at the time of the encounter. The gestational age code is Z3A.__, with the final 2 digits representing the weeks of gestation (for instance, from 27 weeks, 0 days to 27 weeks, 6 days, the final 2 digits will be “27”).
ICD-10-CM also has different conventions when it comes to timing as it relates to conditions that are present during the episode in which the patient delivers. When this is the case, an “in childbirth” code must be selected instead of assigning the diagnosis by trimester, if one is available. There also are codes that are specific to “in the puer-perium,” and these generally will be reported after the patient has been discharged after delivery but also would be reported if there is no “in childbirth” code available at the time of delivery. The code categories to which this concept will apply are:
- preexisting hypertension
- diabetes mellitus
- malnutrition
- liver and biliary tract disorders
- subluxation of symphysis (pubis)
- obstetric embolism
- maternal infectious and parasitic diseases classifiable elsewhere
- other maternal diseases classifiable elsewhere
- maternal malignant neoplasms, traumatic injuries, and abuse classifiable elsewhere.
Taking time to read a code description from a search program or drop-down menu also will be important because some codes refer to “of the puerperium” versus “complicating the puerperium” or “in the puerperium.” The first reference means that the condition develops after delivery, while the second and third terms mean that it developed prior to delivery. For example, code O90.81, Anemia of the puerperium, refers to anemia that develops following delivery, while code O99.03 Anemia complicating the puerperium, denotes preexisting anemia that is still present in the postpartum period.
Multiple gestation coding and the 7th digit
The first thing you will notice here is that several code categories require a 7th numeric character of 0 or 1 through 9. This rule will apply to the following categories:
- complications specific to multiple gestation
- maternal care for malpresentation of fetus
- maternal care for disproportion
- maternal care for known or suspected fetal abnormality and damage
- maternal care for other fetal problems
- polyhydramnios
- other disorders of amniotic fluid and membranes
- preterm labor with preterm delivery
- term delivery with preterm labor
- obstructed labor due to malposition and malpresentation of fetus
- labor and delivery with umbilical cord complications.
A 7th character of 0 will be reported if this is a singleton pregnancy, and the numbers 1 through 5 and 9 refer to which fetus of the multiple gestation has the problem. The number 9 would indicate any fetus that was not labeled as 1 to 5.
The trick in documentation will be identifying the fetus with the problem consistently while still recognizing that, in some cases, such as fetal position, twins may switch places. On the other hand, if one fetus is small for dates, chances are good that this fetus will remain so during pregnancy when twins are present.
A code will be denied as invalid without this 7th digit, so it will be good practice for the clinician to document this information at each visit.
Additional information in regard to multiple gestations will be the chorionicity of the pregnancy, if known, but there will also be an “unable to determine” and an “unspecified” code available if that better fits the documentation for the visit. Note, however, that there is no code for a trichorionic/ triamniotic pregnancy; therefore, only the unspecified code would be reported in that case. In addition, if there is a continuing pregnancy after fetal loss, the cause must be identified within the code (that is, fetal reduction, fetal demise [and retained], or spontaneous abortion).
Documentation requirements for certain conditions
If you plan on reporting any complication of pregnancy at the time of the encounter, information about that condition needs to be part of the antepartum flow sheet comments. If, at the time of the encounter, a condition the patient has is not addressed and the entire visit involves only routine care, you would report the code for routine supervision of preg- nancy rather than the complication code. If the complication is again addressed at a later visit, the complication code would be reported again for that visit. The routine supervision code and the complication code cannot be reported on the record for the same encounter under ICD-10-CM rules.
