1. CHAPTER-SPECIFIC GUIDELINES (ICD-10-CM CHAPTERS 15-21)
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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
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.
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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
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4. Routine Prenatal Visits
Routine outpatient prenatal visits with no complications = Z34 category code
First listed
Routine high-risk prenatal visits = O09 category code
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5. 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.
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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
The unspecified trimester code should rarely be reported.
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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
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8. 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.
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9. 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.
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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
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.
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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
Poorly controlled diabetes mellitus during pregnancy can lead to serious complications for both mother and fetus.
May result in miscarriage or stillbirth.
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12. 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.
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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 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.
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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
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.
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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
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.
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16. 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…)
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17. 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
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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
Includes burn codes from radiation or electricity.
Current burns are classified by:
Depth
Extent
Agent (X code)
(Cont’d…)
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19. 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.”
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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
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.
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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
Examples of poisoning include:
Error in drug prescription
Intentional overdose
Combination of drugs taken
Interaction of drugs and alcohol
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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
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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)
When suspected abuse, neglect, or maltreatment is ruled out, report Z04.71 for an adult and Z04.72 for a child.
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24. CHAPTER-SPECIFIC GUIDELINES (ICD-10-CM CHAPTER 15-21)
Conclusion CHAPTER 7
CHAPTER-SPECIFIC GUIDELINES (ICD-10-CM CHAPTER 15-21)
Slide 24
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