CHAPTER-SPECIFIC GUIDELINES (ICD-10-CM CHAPTERS 15-21) SXS13ierPPTintC07_P2

Pregnancy, Childbirth, and the Puerperium, Chapter 15 O00-O9A Any condition that occurs during pregnancy, childbirth, or puerperium is a complication Unless physician documents it neither: Affects the pregnancy Is affected by the pregnancy Chapter 15 codes are never used on the record of the newborn. Coders may find it helpful to code the mother’s and baby’s records at the same time. Conditions documented on the birth certificate may appear on the newborn’s record but not the mother’s record. Additional documentation to support coding may have to be obtained from the physician. SXS13ierPPTintC07_P2

Sequencing Priority Chapter 15 codes have sequencing priority of codes from other chapters Z33.1, incidental pregnancy state, is reported if the physician documents incidental status Chapter 15 codes are only for mother’s record Never newborn’s record SXS13ierPPTintC07_P2

Routine Prenatal Visits Routine outpatient prenatal visits with no complications = Z34 category code First listed Routine high-risk prenatal visits = O09 category code SXS13ierPPTintC07_P2

Outcome of Delivery Outcome of delivery Z37 category code Only reported once On mother’s record Category Z37, Outcome of delivery, can be assigned as an additional coding to the mother’s record. An outcome of delivery code should be included on every maternal record when a delivery has occurred. SXS13ierPPTintC07_P2

Trimester and Time Periods Majority of codes, final character indicates trimester Trimester calculated from last menstrual period (LMP) First trimester: less than 14 weeks 0 days Second trimester: 14 weeks 0 days to less than 28 weeks 0 days Third trimester: 28 weeks 0 days until delivery Peripartum = last month of pregnancy to 5 months postpartum Postpartum = immediately after delivery to 6 weeks after delivery The unspecified trimester code should rarely be reported. SXS13ierPPTintC07_P2

Ectopic Pregnancy Fertilized ovum implants outside the uterus Reported with category O00, based on: Location of pregnancy Such as: ovarian or tubal Complications associated with ectopic pregnancy: Report category O08 code SXS13ierPPTintC07_P2

Hydatidiform Mole Tumor of the placenta Report with category O01 Secretes hormones Report with category O01 Report complication with category O08 Malignant, report D39.2 Secretes hormones: chorionic gonadotropic hormone, GGH. SXS13ierPPTintC07_P2

Hypertension in Pregnancy Pre-existing hypertension that complicates the pregnancy, delivery, or the five-month period after birth, Category O10 First-listed code Secondary code is assigned to report hypertensive heart disease or hypertensive chronic kidney disease. SXS13ierPPTintC07_P2

Fetal Conditions Category O35 and O36 report fetal abnormalities that affect the care of mother If fetal abnormality does not affect care of mother, do not report O35 or O36 When surgery is performed on the fetus, report a diagnosis code from category O35, to identify the fetal condition. Surgery performed in utero on the fetus, is reported on the obstetric encounter. SXS13ierPPTintC07_P2

Diabetes Mellitus in Pregnancy Type 1 = little or no insulin is produced Controlled with insulin Report long-term use of insulin Type 2 = too little or the body cannot use the insulin that is produced Controlled with diet, medications, and/or insulin May report long-term use of insulin Gestational diabetes develops in 2nd or 3rd trimester in patient who did not have diabetes prior to pregnancy Do not report long-term use of insulin Poorly controlled diabetes mellitus during pregnancy can lead to serious complications for both mother and fetus. May result in miscarriage or stillbirth. SXS13ierPPTintC07_P2

Certain Conditions Originating in the Perinatal Period, Chapter 16 P00-P96 Chapter 16 codes only on newborn’s record Category Z38 reports liveborn according to place of birth and type of delivery First listed Does not report congenital malformation, deformities, or abnormalities Rather report with Q00-Q99 Whose record are Chapter 16 codes never reported on? (Maternal) Chapter 16 codes can be reported throughout the life of the patient, if the condition persist. SXS13ierPPTintC07_P2

Congenital Malformations, Deformation, and Chromosomal Abnormalities, Chapter 17 Q00-Q99 May be a first-listed or secondary diagnosis Sequence as secondary diagnosis with category Z38 code on initial birth record Reported whenever condition is diagnosed Congenital = born with Physician must document abnormality An anomaly is an abnormality of a structure or organ. Congenital refers to an abnormality with which a person is born. The term perinatal applies only to the baby, and postpartum applies only to the mother. SXS13ierPPTintC07_P2

Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, NEC, Chapter 18 R00-R99 Sign = objective evidence of disease Symptom = subjective observation Report symptoms only when no more definitive diagnosis is available Example: Pt complains of pain right lower quadrant. Diagnosis states acute appendicitis. Do not report symptom of pain Signs and symptoms codes are used for encounters until a definitive diagnosis can be made. No specific diagnosis can be made after investigation. Signs and symptoms reported as existing at the time of the initial encounter prove to be transient or cause cannot be determined. A patient fails to return, or is referred elsewhere, and all the coder has is a provisional diagnosis. A more precise diagnosis is not available for any other reason. Certain symptoms that represent important problems in medical care exist, and it might be desirable to classify them in addition to the known cause. SXS13ierPPTintC07_P2

Injury, Poisoning, and Certain Other Consequences of External Causes, Chapter 19 S00-T88 Many codes have 7th characters A initial encounter Receiving active treatment for the injury D subsequent encounter Completed active treatment and is receiving routine care during healing S sequela Direct result of injury, add S to injury code, not to sequela code Would usually report a secondary code from Chapter 20, External Causes of Morbidity, to indicate injury. There are T codes that include the external cause as part of the code description. SXS13ierPPTintC07_P2

Traumatic Fractures Fractures not indicated as Assign 7th character Open or closed, report as closed Displaced or not displaced, report as displaced Assign 7th character A initial encounter for closed fracture B initial encounter for open fracture D subsequent encounter for fracture with routine healing G subsequent encounter for fracture with delayed healing K subsequent encounter for fracture with nonunion S sequela (Cont’d…) SXS13ierPPTintC07_P2

Traumatic Fractures Multiple fractures, sequence according to severity (…Cont’d) Multiple fractures, sequence according to severity If dislocation and fracture of same bone, report only fracture Category M80 reports non-traumatic fracture for patients with osteoporosis Even if injury by trauma Pathological fracture occurs due to disease or weakness SXS13ierPPTintC07_P2

Burns and Corrosions Thermal burns from heat source Except sunburn Corrosion burns due to chemicals Guidelines same for burns and corrosions Burns classified by depth: 1st erythema 2nd blistering 3rd full-thickness Includes burn codes from radiation or electricity. Current burns are classified by: Depth Extent Agent (X code) (Cont’d…) SXS13ierPPTintC07_P2

Burns and Corrosions Sequence first Multiple burns, same area (…Cont’d) Sequence first Highest degree of burn Multiple burns, same area Report only the highest degree burn Infected burns Use additional code for infection Late effects of burns Report with burn or corrosion code + 7th character “S” Nonhealing burns are coded as acute burns. If different degrees of burns are documented at the same site, assign a code to burns of highest degree only. Second-degree burns may also be referred to as “partial-thickness burns.” SXS13ierPPTintC07_P2

Adverse Effects, Poisoning, Underdosing, and Toxic Effects T36-T65 Combination codes that include Substance External cause Sequence these codes 1st Follow with code(s) that specify nature Do not code directly from the Table of Drugs and Chemicals. Assign a code for adverse effect when the drug was correctly prescribed or administered. SXS13ierPPTintC07_P2

Poisoning Assign code from categories T36-T50, poisoning codes Report any associated intent Such as, accidental, intentional, etc. Report all manifestations of poisoning Such as, vomiting Examples of poisoning include: Error in drug prescription Intentional overdose Combination of drugs taken Interaction of drugs and alcohol SXS13ierPPTintC07_P2

Drug Adverse Effect or Poisoning Adverse Effect: Occurs when drug is taken correctly but patient has negative response Poisoning: Occurs when drug is incorrectly taken SXS13ierPPTintC07_P2

Abuse, Neglect, or Maltreatment Sequence first (T74.- or T76.-) Medical documentation states Abuse or neglect, code as confirmed Suspected, code as suspected Confirmed cases of abuse or neglect Report an assault code (X92-Y08) to indicate cause of physical injury Report perpetrator code (Y07) When suspected abuse, neglect, or maltreatment is ruled out, report Z04.71 for an adult and Z04.72 for a child. SXS13ierPPTintC07_P2

CHAPTER-SPECIFIC GUIDELINES (ICD-10-CM CHAPTER 15-21) Conclusion CHAPTER 7 CHAPTER-SPECIFIC GUIDELINES (ICD-10-CM CHAPTER 15-21) Slide 24 SXS13ierPPTintC07_P2