Lecture Notes: Diagnosis and Procedure Coding for Labor and Delivery
Introduction
- Presenter: Terry Tropin
- Qualifications:
- Master's in Healthcare Administration Informatics
- RHIA and CCSP certifications
- AHIMA-approved ICD-10 trainer
- Author of coding books
- Over 20 years of teaching experience
Topics Covered
- Diagnosis Coding
- Procedure Coding
- Notes and Guidelines
Diagnosis Coding
Digits for Trimesters and Fetuses
- Indicate pregnancy phase: trimester, childbirth or postpartum.
- Use specific digits for complications (e.g., hypertension, preeclampsia).
- Guidelines for using digits:
- Use childbirth digits if delivery occurs.
- Use trimester digits if childbirth digits are unavailable.
Examples
- Moderate Preeclampsia: Use O14.04 for childbirth digit.
- Deep Vein Thrombosis: Use O22.33 with trimester digit.
Digits for Fetus
- Single fetus: use 7th digit zero.
- Multiple fetuses: digit indicates which fetus is affected.
Sequencing Guidelines
- Principal diagnosis is the reason for admission.
- If admitted for multiple reasons, use the one most related to delivery.
- Include additional codes for complications.
Special Codes and Categories
- O09: Supervision of high-risk patients.
- O30-O48: Maternal care for fetus and potential delivery issues.
- O60-O77: Complications of labor and delivery.
- O80: Uncomplicated delivery.
Procedure Coding (PCS)
Root Operations
- Section 1: Obstetrics
- Body Part: Products of conception
- Root Operations: drainage, extraction, delivery, etc.
Body Part Values
- Concepts like products of conception, retained products, ectopic conception.
Specific Procedures
- Cesarean Delivery: Extraction; qualifier depends on incision location.
- Vaginal Delivery: Manually assisted, spontaneous.
- Episiotomy: Coded to surgery section.
Examples and Coding
- Amniocentesis: Drainage
- Forceps Delivery: Extraction
- Episiotomy Repair: Surgery section for repair.
Notes for ICD-10-CM and PCS Books
- Write notes in coding books to remember guidelines.
- Circle important notes, e.g., for O80, all criteria must be met.
- PCS Book: Write specific examples next to tables.
Conclusion
- Contact information for slides and books.
- Encouragement to subscribe for more content.
Study Tip: Remember the role of timing and specific conditions during pregnancy and delivery for selecting the appropriate codes.