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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
Hypertension. Documentation needs to state whether the hypertension is preexisting or gestational. If it is preexisting, it needs to be identified as essential or secondary. If the patient also has hypertensive heart disease or chronic kidney disease, this information should be included, as different codes must be selected.
Diabetes. The documentation needs to state whether it is preexisting or gestational. If preexisting, you must document whether it is type 1 or type 2. If it is type 2, you must report an additional code for long-term insulin use, if applicable. The assumption for a woman with type 1 diabetes is that she is always insulin-dependent, so long-term use is not reported separately. Note, however, that neither metformin nor glyburide is considered insulin and there is no mechanism for reporting control with these medications.
If diabetes is gestational, you must indicate whether the patient’s blood glucose level is controlled by diet or insulin. If both, report only the insulin. There is no code for the use of other medications for the control of gestational diabetes, so you would have to report an unspecified code in that case.
Also note that ICD-10-CM differentiates between an abnormal 1-hour glucose tolerance test (GTT) and gestational diabetes. Unless a 3-specimen or 4-specimen GTT has been performed and results are abnormal, a diagnosis of gestational diabetes should not be reported.
An additional code outside of the obstetric complication chapter is required to denote any manifestations of diabetes. If there are none, then a diabetes uncomplicated manifestation code must be reported.
Preterm labor and delivery. Your documentation must clearly indicate whether the patient has preterm labor with preterm delivery or whether the delivery is term in addition to the trimester. For instance, if you document that Mary presents with preterm labor at 27 weeks, 2 days and delivers a girl at 28 weeks, 6 days, your code will describe Preterm labor second trimester with preterm delivery third trimester. However, if Susan presents with preterm labor at 30 weeks, 2 days and is managed until 37 weeks, 1 day, when she delivers a baby boy, your code would describe Term delivery with preterm labor, third trimester.
New coding options
Among the new coding options under ICD-10-CM:
- Abnormal findings on antenatal screening. These would be reported when the antenatal test is abnormal but you have not yet determined a definitive diagnosis.
- Alcohol, drug, and tobacco use during pregnancy. If you report any of these codes, you must also report a manifestation code for the patient’s condition. If the use is uncomplicated, you would report that code instead.
- Abuse of the pregnant patient. You can report sexual, physical, or psychological abuse, but you also must report a code for any applicable injury to the patient and identify the abuser, if known.
- Pruritic urticarial papules and plaques of pregnancy
- Retained intrauterine contraceptive device in pregnancy
- Maternal care due to uterine scar from other previous surgery. This would mean a surgery other than a previous cesarean delivery.
- Maternal care for (suspected) damage to the fetus by other medical procedures
- Maternal care for hydrops fetalis
- Maternal care for viable fetus in abdominal pregnancy
- Malignant neoplasm complicating pregnancy
- Failed attempt at vaginal birth after previous cesarean delivery
- Supervision of high-risk pregnancy due to social problems (for instance, a homeless patient)
- Rh incompatibility status (when you lack confirmation of serum antibodies and are giving prophylactic Rho[D] immune globulin).
CMS takes steps to ease transition to ICD-10-CM
To help health care providers get “up to speed” on the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), which takes effect October 1, 2015, the Centers for Medicare and Medicaid Services (CMS) has launched a new series for specialists. A guide tailored to ObGyns is available at http://roadto10.org/example-practice-obgyn. The guide includes:
Parting words
ICD-10-CM may seem like the end of the world, but its difficulty is exaggerated. If you fail to prepare, you will fail, and money coming in the door may be affected. If you prepare with training and practice, you will have a short learning curve. I wish you all the best. If you have specific questions about your practice, don’t hesitate to let us know so they can be addressed early.
