Medical Coding II Seminar 6

Unit 6 Overview Reading, Understanding ICD-9-CM Coding: Chapters 16, 19, 20 Graded Assignments Seminar, Attend Seminar or Complete Option 2, 20 Points Exercises, Challenge exercises derived from your textbook, 20 points Quiz, 60 points

Mom’s Codes versus Baby’s Codes Health record for mother Chapter 11 codes (630–677) are used to describe the maternal conditions and reported only on mother’s record V27 category for outcome of delivery Health record for baby V30 category for newborn status Codes 760–763 and 764–779 identify conditions of newborn

Coding the Mom’s Record

Index Entries Pregnancy Labor Delivery Puerperium, puerperal, or postpartum Many indentations under each term Requires close attention to index entries

Terms of Pregnancy Preterm: Delivery before 37 completed weeks of gestation Term: Delivery between 38 and 40 completed weeks Postterm: Delivery after 40 completed weeks through 42 completed weeks Prolonged: Delivery after 42 completed weeks

Classification of Pregnancy 633, Ectopic pregnancy 640–649, Complications mainly related to pregnancy 650–659, Normal delivery and other indications for care 660–669, Complications: labor and delivery 670–677, Complications of the puerperium 678–679, Other maternal and fetal complications

Pregnant Patient Obstetrical patients require a code from 630–679 from chapter 11 of ICD-9-CM If patient’s treatment is not affecting the pregnancy, assign code V22.2, rather than a code from chapter 11 Physician is responsible for documenting that a condition is not affecting the pregnancy

Sequencing of Codes Principal diagnosis selection Circumstances of the encounter or admission determine the principal diagnosis If no delivery, principal diagnosis should identify the principal complication that necessitated the admission

Sequencing of Codes (continued) Principal diagnosis selection When delivery occurs, principal diagnosis should identify the main circumstance or complication of the delivery If a cesarean delivery was performed, principal diagnosis should reflect the reason for the admission

Sequencing of Codes (continued) Principal diagnosis selection Routine prenatal visits without the presence of any complication V22.0, Supervision of normal first pregnancy V22.1, Supervision of other normal pregnancy V22.0 or V22.1 are not used with additional codes from chapter 11

Sequencing of Codes (continued) Principal diagnosis selection Prenatal visits in high-risk pregnancy Code from category V23, supervision of high-risk pregnancy, should be sequenced first Additional codes from chapter 11 should be assigned to describe specific complication

Fifth-Digit Subclassification Assignment of fifth digit describes the episode of care Fifth digits required 640–649 651–659 660–669 670–676 678–679

Fifth-Digit Subclassification (continued) 0 – unspecified as to episode of care or not applicable 1 – delivered, with or without mention of antepartum condition 2 – delivered, with mention of postpartum complication (complication developed after delivery but before woman was discharged from hospital)

Fifth-Digit Subclassification (continued) 3 – antepartum condition or complication may be described as “undelivered” 4 – postpartum condition or complication woman delivered during earlier episode of care

Fifth-Digit Subclassification (continued) Fifth digit of 0 should not be used if at all possible, find out more about the patient When delivery has occurred during current episode of care, fifth digit is either 1 or 2 Fifth digit of 1: Patient delivered, may or may not have had an antepartum condition Fifth digit of 2: Patient delivered and developed a complication after delivery but before discharge

Fifth-Digit Subclassification (continued) Fifth digit of 3 Delivery has not occurred during this episode of care Patient remains pregnant; undelivered Fifth digit of 4 Delivery has occurred during a previous episode of care Patient care is occurring less than 42 days after delivery and a postpartum condition exists

Fifth-Digit Subclassification (continued) Fifth digits of 1 and 2 can be used on different codes for the same episode of care as both indicate a delivery has occurred but complication developed at different times Fifth digit of 3 can only be used with other codes with fifth digit of 3 Fifth digit of 4 can only be used with other codes with fifth digit of 4

Obstetrical Procedures Volume 3 Main term is delivery or other procedure title Category 72, Forceps, vacuum, and breech delivery Category 73, Other procedures inducing or assisting delivery Category 74, Cesarean section and removal of fetus Category 75, Other obstetric operations

Coding the Baby’s Record

Newborn Coding Guidelines Newborn period is defined as beginning before birth and lasting through the first 28 days after birth All clinically significant conditions noted on routine newborn examinations should be coded Physician documentation indicates whether a condition is clinically significant

Newborns, Congenital Anomalies and Perinatal Conditions Newborns may have congenital anomalies (740–759 ) and certain other conditions that originate in the perinatal period (760–779) Coding the birth of an infant First code is from categories V30–V39 Additional code from 740–759 and/or 760–779 assigned for additional conditions

Newborn Coding Guidelines (continued) A newborn condition is significant if it requires: Clinical evaluation Therapeutic treatment Diagnostic procedures Extended length of hospital stay Increased nursing care and/or monitoring If it has implications for future healthcare needs

Newborn Coding Guidelines (continued) Codes should be assigned for conditions that have been specified by the provider as having implications for future health care needs Codes from the perinatal chapter should not be assigned unless the provider has established a definitive diagnosis

Principal versus Additional Diagnosis Hospital stay at time of birth Principal diagnosis in V30–V39 section Additional diagnosis for congenital anomaly or other condition such as prematurity Infant transferred to second hospital Follow definition of principal diagnosis Generally the reason for transfer, such as anomaly, perinatal condition, or complication V30–V39 is not used again

Questions?