Today we're going to look at the
guidelines for Chapter 15, which is your
OB chapter in the code book. Those
covers conditions of pregnancy, childbirth
and the puerperium. We're going to look at
some notes at the very beginning of
Chapter 15. The first has to do with
maternal records. Codes from this chapter
are for use only on maternal records,
never on the baby's records. The
codes from this chapter are for use for
conditions related to or aggravated by
the pregnancy, the childbirth, or the puerperium.
Trimesters are defined at the
very beginning of Chapter 15. If you can
remember the numbers 14 and 28, you're
going to be very close, if not correct
right on. Most of the time, a doctor just
gives you weeks (of gestation). Very seldom do they talk
about days. Occasionally, you do see them.
All of your maternal cases are (typically) going to show
a category code from Z3A, indicating
weeks of gestation. This code
category Z3A is found after Z36 in
Chapter 21. Chapter 21 contains the status
codes, in the back of the codebook. There
are several Z codes that you use in the
pregnancy chapter, but the Z3A is
there, after Z36. Again, this is only
for use on the mother's records, There
is an instructional note under the Z3A
category that says "code first
complications of pregnancy, childbirth and
the puerperium. Almost always that Z3A
code is at the end of your list of
diagnoses. There are Excludes 1 and
Excludes 2 notes at the beginning of
Chapter 15 that we need to pay attention
to. Excludes 1 tells us that
supervision of a normal pregnancy is
going to fall under the Z34 category
code. You will not be using any codes
from Chapter 15 if you are merely seeing
the mother for supervision of a normal
pregnancy. The Excludes 2 notes, those
conditions you can have along with
Chapter 15 and those would be the
conditions as listed, the mental and
behavioral disorders associated with the
puerperium (F53 category)
obstetrical tetanus (A34), postpartum necrosis
of the pituitary gland (E23.0) and a
puerperal osteomalacia (M83.0).
You can have any of
those along with conditions found in
Chapter 15. Okay, let's start on our
guidelines. What I do want to say is I did
not cover all of them. I recommend that
you get used to reading all of the
guidelines but just for the sake of
space and time, I picked out those that
are covered in previous code books and
which give us examples to help us look
at the guidelines. The first scenario is
a bladder abscess in a pregnant patient.
25 weeks gestation. You are going
to code "pregnancy complicated by
abscess, bladder. There's a 5th character
added to that code to indicate the
trimester and another instructional note
that says "use additional code to
identify the organism". We are not told what the
organism is in this particular scenario.
Then you would code the cystitis. It tells
us for a bladder abscess, we are going to code it as
cystitus, specified type, which we've done.
Then we've added the Z3A.25 code.
I have two guidelines here. One is
telling you about the sequencing of the
codes and a second guideline has to do
with adding that final character for the
trimester. Final character for trimester
is our next guideline here. Pregnant patient, 21 weeks
gestation, admitted with excessive
vomiting. The pathway's given there as
well as the codes and it tells us in the
rationale if a trimester is not a
component of a code, it's because the
condition always occurs in a specific
trimester or the concept of trimester is
not applicable. In the ICD-10-CM
classification, they break it out as
before 20 weeks and after 20 weeks
gestation when it comes to excessive
vomiting. With some conditions, it is not
specific to the trimester.
Another example for that final character for
trimester (guideline) that's given, patient was
admitted in labor with a pre-existing type 2
diabetes, controlled by oral hypoglycemic
drugs. I give you there the pathway. You
notice it is "Delivery complicated by"
because the patient is in labor. If it's
just a pregnancy situation, they're not
in labor, it's really "pregnancy
complicated by". You follow your
instructional notes to add any
additional codes that you need to add
and then there's the rationale. This rationale tells us that when there is an
"in childbirth" option for the complication,
be sure to use that "in childbirth" code.
In this case, there was one for O24.12.
The next guideline has to do with the selection of
trimester for inpatient admissions that
encompass more than one trimester.
In other words, you come in in one
trimester and then you go into the next
trimester while you are an inpatient. The
example that's given is a patient
admitted at 27 weeks six days for
hemorrhaging from a complete placenta previa
and three days after she was admitted,
now she's at 28 weeks one day, she
developed gestational hypertension. I
have here the rationale of how I coded
that, showing you those additional
characters I added. The biggest thing
is the patient was admitted with the
placenta previa with hemorrhage so
that's going to be your principal
diagnosis and it's going to capture the
second trimester. The next condition that's
given, the gestational hypertension,
came in her third trimester so it is
going to be given that final character
of "3" for the third trimester. So you've
got the same patient with codes that are
showing different trimesters depending
on when the condition developed. Again
your guidelines are showing you how to
do that.
The next guideline has to do with the
7th character for fetus identification.
When you have a situation where it's
important that you identify the fetus
when you can. It's not uncommon when you have
multiple gestations, if
anything is wrong with any of the fetuses, the
documentation will tell you which one
when they know. This particular scenario
is a maternal patient with twin
gestations identifies fetus B to be in a
breech position. So that's going to be a
"pregnancy complicated by breech
presentation" and we add the 7th
character "2" in this case to identify
fetus B or fetus 2. We needed the 5th and 6th
characters of X as placeholders in order
to add that 7th character as a fetus
identification. Sometimes people get in
the habit of thinking of a 7th
character is going to always be the
encounter, whether it's initial or
subsequent or sequelae. You really have
to go by what your categories are telling
you, your coding instructions. When
it comes to maternal codes in this
particular code, that 7th character
has nothing to do with the encounter. The
7th character is identifying the
fetus. You also see down at the bottom, the
rationale. If you had a single gestation,
you would just use "0" as your 7th character or
if your documentation doesn't tell
you enough to let you know what this is
affected or you can't clinically
determine which fetus is affected,
then you're going to also use the "0"
as your 7th character. The next guideline
one has to do when a delivery occurs.
Maternal patient with diet-controlled
gestational diabetes admitted at
38 weeks in obstructed labor due to a
footling presentation and a caesarean
was performed
because of that
malpresentation.
Codes are given there.
Delivery, complicated by, obstructed
labor, due to a footling presentation and
then you also have to have a delivery
complicated by gestational diabetes
which you differentiate as diet
controlled. The weeks of gestation are
there as well as the outcome of your
delivery. This is an additional coding
guideline we haven't mentioned yet but
there are directions that tell us
anytime you have a birth, you have to
have an outcome of delivery code even if it's
a stillborn. There is a code a Z code
for stillborn delivery. There's the code
for single liveborn or for multiples.
It is important to pick the correct code under
your outcome of delivery. You also notice
in the first guideline that's quoted, the
condition that is why the patient came
into a hospital is going to be your
principal (diagnosis), so I chose a delivery
complicated by the obstructed labor as
the principal diagnosis. Here is another one for this
guideline. At 39
weeks gestation, maternal patient
presents with hemorrhage with coagulation
defect. The next day she goes into labor
and she eventually delivers a single
live birth by C-section due to arrested
active phase of labor. Two things are
going on, both addressing our guideline.
The patient has presented with the
hemorrhage with coagulation defect so
that's going to be your principal
diagnosis but also you're going to add
the "Delivery, arrested active phase"
because you know that was the reason why
she had a cesarean section. if you remember from
some of our earlier podcasts, you must
always have a medical necessity for why
a procedure is done and in the case of a
delivery, if a cesarean is done, you have
to be sure that your diagnoses are
going to give medical necessity for that
procedure. In this case, our documentation
tells us the cesarean was due to the arrested
active phase of labor so we're going to
make sure that that code is there.
This is one of those examples where your
principal procedure, which is your
caesarean, does not necessarily match
your principal diagnosis but you can
justify the way you have your codes
sequenced by the guidelines. Fetal
conditions affecting the management of
the mother -these are codes from
Categories O35 and O36. Patient is seen
for spotting, 15 weeks into her pregnancy.
The doctor suspects fetal hydrocephalus.
The pregnancy is complicated by the
spotting. I have it there. The 6th character "2"
identifying the second trimester.
Remember, 14 weeks is your first trimester
break off and then 15 weeks,
you're into your second trimester. Then (code) the
weeks of gestation. Then Ihave (in purple font color) "the fact that the fetal
condition exists does not
justify assigning a code from this
series to the mother's record. In other
words, it's not appropriate to use
categories O35 and O36 just because you have
something going on. That's the point they are
trying to make in this example.
HIV infection in pregnancy, childbirth, and
the puerperium. A previously asymptomatic HIV
patient who is 13 weeks pregnant is
admitted with oral thrush. She was
previously asymptomatic. Now she is
symptomatic, so you're going to be using
that B20 code. If this were not a
pregnant patient, B20 would be your
principal diagnosis because she has an
HIV-related condition (the oral thrush is HIV-related).
When it comes to OB, you have a specific code that
tells you you're going to sequence
according to Chapter 15 guidelines
which state you're going to use the
"pregnancy complicated by the HIV" as your
principal diagnosis. You're going to add
your HIV B20 diagnosis, then the oral
thrush and then the weeks of gestation.
I have the guideline quoted there. You
can also look back in Chapter 1
guidelines and there is a specific
guideline that points you to the Chapter
15 coding guidelines when you have a
pregnant patient with HIV infection.
I also want to point out that
once a patient has that B20 diagnosis, she
will always carry the B20 diagnosis in
future codes. You don't ever go back to
being "asymptomatic" once you've had an
HIV related condition. The next guideline
has to do with sepsis and septic shock
complicating abortion, pregnancy,
childbirth, and the puerperium.
Patient is seen several days after a
miscarriage with sepsis and the cultures
return with Methicillin susceptible
Staphylococcus aureus (MSSA). A miscarriage is
an abortion, like a spontaneous abortion
and it is complicated by sepsis and that
gives us the O03.87 code. There's an
instructional note with that code that
says "use additional code to identify
the infectious agent" which we know is
the MSSA. I have there the pathway for how
you would get that code and then I have
the rationale. When you have a Chapter 15
code for sepsis complicating abortion,
pregnancy, childbirth, and the puerperium,
a code with a specific type of
infection is assigned as an additional
diagnosis meaning the abortion code is
going to be your principal diagnosis and
then the cause of the infection is going
to be your secondary diagnosis. Just a
reminder, if you have a "complete" abortion,
meaning all products of conception have
been removed; an "incomplete" abortion
meaning you have retained products of
conception. Abortion is a term, at least
in the ICD-10-CM that covers both a
spontaneous abortion or an induced
abortion. "Spontaneous" meaning the mother's
body is expelling the fetus. Of course
(the use of) instrumentation to remove the fetus
would be "medical" or "induced" abortion.
This guideline has to do with poisoning,
toxic effects, adverse effects and
underdosing in a pregnant patient. Most
the time, when you're coding pregnancies
or adverse effects, that's going to be your
principal (diagnosis). That T code is going to be
your principal diagnosis. This is not so in a
pregnant patient. This patient is
admitted with accidental carbon monoxide
poisoning from the gas heating implement
and the patient's 18 weeks pregnant.
there is a pregnancy code,
(pregnancy) complicated by poisoning that then
refers you to the Table of Drugs and
Chemicals to get the T code to identify
the carbon monoxide poisoning. I
chose "piped gas" because, from our
scenario, it says "poisoning from a gas
heating implement" and
the gas is being piped into this implement
and that's how the patient got the
accidental carbon monoxide poisoning.
Of course you add your weeks of gestation
code (Z3A.18) and then you see the rationale.
This particular coding guidelines tells
you how to sequence these codes.
The next guideline is Uncomplicated delivery with
resolved antepartum complication.
In other words, something has happened
during the pregnancy but by the time
patient delivered, it was resolved and
therefore it's not going to affect your
coding. Patient presents in labor at 39
weeks and delivers a healthy newborn. The
patient had abnormal glucose levels in
her first trimester, which have since
resolved.Because they have resolved,
you're only going to code this
uncomplicated delivery and O80 as well
as the outcome of delivery of a single
live born Z37.0. The guideline tells us
that code O80 can be used if the
patient had a complication at some point
but that complication is not present at
the time of admission. The only time you
can use an O80 code is when (the delivery) is
uncomplicated, a vaginal delivery and a
single live born. If there were no problems at all, you
can use that code (O80). Otherwise, you
have to use a different code.
Pregnancy-related complications after
six-week period. This is a good
example of how you can have things
happen after the postpartum period that
are related back to the pregnancy but
your documentation has to tell you that.
The coder could not know that unless the
doctor specifically tied the condition
back to the pregnancy. In this scenario,
the patient is admitted for varicose veins
in her legs. She had a little boy three
months ago. The varicose veins appeared
one month ago. The doctor attributes the
patient's pregnancy as the cause of the varicose
veins, which continue to be painful,
bothering the patient and she is seeking
surgical relief. So because the doctor
has stated they are related, you would
look under your puerperal codes and look
under varicose veins, identify them as
those in the legs and that would be an
O87.4 code. Again, your documentation is
what's driving your selection of that
code. Otherwise, you would not be coding a
pregnancy-related complication for
someone who had a baby three months ago.
The last guideline we are going to talk
about is retained products of conception
following an abortion. In this case, the
patient was seen two days ago for what
they believed to be a complete
spontaneous abortion but she's returning
today for a urinary tract infection.
When they did an ultrasound, it showed
retained products of conception. In other
words, she did not have a "complete"
spontaneous abortion. She had an
"incomplete" abortion and there is a code
indexed there for incomplete abortion
complicated by infection, urinary tract
O03.38. I've given there the
rationale. I know I've gone over these
quickly, there are a lot of guidelines in
Chapter 15. Please review all of them in
preparation for your exams and when you
are coding Chapter 15 homework. If you have
any questions, post to the discussion
board. I will do my best to answer them.
Thank you so much.