Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 1 CHAPTER 7 CHAPTER-SPECIFIC GUIDELINES (ICD-10-CM CHAPTERS 15-21)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 2 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

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 3 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

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 4 Routine Prenatal Visits Routine outpatient prenatal visits with no complications = Z34 category code –First listed Routine high-risk prenatal visits = O09 category code –First listed

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 5 Outcome of Delivery Outcome of delivery – Z37 category code –Only reported once –On mother’s record

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 6 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

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 7 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

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 8 Hydatidiform Mole Tumor of the placenta –Secretes hormones Report with category O01 Report complication with category O08 Malignant, report D39.2

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 9 Hypertension in Pregnancy Pre-existing hypertension that complicates the pregnancy, delivery, or the five-month period after birth, Category O10 –First-listed code

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 10 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

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 11 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

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 12 Certain Conditions Originating in the Perinatal Period, Chapter 16 P00-P96 Chapter 16 codes only on newborn’s record –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

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 13 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 Reported whenever condition is diagnosed Congenital = born with Physician must document abnormality

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 14 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

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 15 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

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 16 Traumatic Fractures Fractures not indicated as –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…)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 17 Traumatic Fractures (…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

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 18 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 (Cont’d…)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 19 Burns and Corrosions (…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”

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 20 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

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 21 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

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 22 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

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 23 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)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 24 Conclusion CHAPTER 7 CHAPTER-SPECIFIC GUIDELINES (ICD-10-CM CHAPTER 15-21)