welcome i'm terry troppen and today i'll be describing diagnosis and procedure coding for labor and delivery first let me tell you a little bit about myself i have a master's in healthcare administration informatics from the university of maryland global campus and have rhia and ccsp certifications i'm also an ahima approved icd-10 trainer i taught health information technology at montgomery college in maryland for over 20 years i've also written books on coding you can see them listed right here so i wrote a book on evaluation and management coding cm coding and pcs coding these books are available on amazon and updated every year or as needed if you would like to purchase a copy of these slides in this presentation contact me at terri.tropin gmail.com i would appreciate it if you would subscribe to my channel um a picture over here on the side just click on that and you can subscribe okay so this is what i'm going to talk about today first i'm going to talk about diagnosis coding and the digits for trimesters and fetuses which is one of the most confusing part of parts of this chapter then we're gonna talk about some guidelines and then different codes codes o thirty to o forty codes o sixty to o seventy seven and then the encounter for delivery codes 080 to 082 and then the special considerations special guidelines for paraparty and cardiomyopathy and then other obstruct obstetric conditions and then z codes i'm also going to talk about pcs codes we're going to talk about the root operations the body part values qualifier values and specific procedures and finally i'm going to talk about notes to make in your icd-10-cm and your pcs books in order to make finding these codes a little bit easier and remembering the guidelines a little bit easier so let's start with diagnosis codes diagnosis codes have digits to indicate what phase of the pregnancy the patient is in different digits indicate the trimester if the patient is giving birth during this administration admission or the postpartum period for example for a patient with hypertension in the beginning of the pregnancy you would have a digit one here for first trimester digit two for second third the third trimester two for complicating childbirth so during the um delivery admission and then after delivery in the purporium now all codes in this category 0 10 include digits for in child birth but not all code categories do and i'm going to talk about that a lot and it's really quite confusing but we'll talk about it so here you go what do you what do you do if there are no digits for in childbirth most codes do some codes do but other codes do not they may only have trimesters listed they may only have they may have no child birth at all they may have no digits for trimester or childbirth so what do you do if that happens if you need to do one of these codes so if a delivery occurs during the current admission and the appropriate code the code you're going to use has a digit for in child birth obviously use the code with the digit for in child birth but if it does not if there's no in childbirth but there's trimester digits use the code for the third for the current trimester so here's an example some examples patient admitted with moderate preeclampsia delivered two days later use code 014.04 because this code does have a digit for in childbirth on the other hand if the patient is admitted in at 30 weeks with deep flammable thrombosis phlebothermosis delivered two days later used o22.33 this co22 does not have an in childbirth option so we're going to use this digit 3 because she's in the third trimester now you're also going to code for the deep vein thrombosis but that's really not relative here okay so we also have digits for the fetus this is one of the things that's confusing about just so many digits to indicate so many things now i have a video up on this channel for uh using digits in pregnancy and if this is something you want to learn more about you can check on that video okay digits for the fetus now the patient only has one fetus use seventh digit zero if as multiple fetuses but but which one has the problem you also use a zero so if it's just if it's the problem is in fetus one use a one fetus two use a two v is three is a three four four five five or if it's more than five then use a nine so what we're saying is if a patient is pregnant with three fetuses and fetus two has a specific condition use the seventh bit digit two to indicate that its feet is two so it's not the total number of fetuses if the fetus with whatever the problem happens to be there are also guidelines concerning sequencing of obstetric codes so the reason the patient is being admitted is sequenced first okay she's admitted and delivered during that admission do the uh one that why why was she admitted okay if multiple conditions prompted the condition the admission sequence the one most related to the delivery as the principal diagnosis and use it the digit for childbirth if it's available so theoretically a patient could be admitted for something and then delivers during that admission for a reason unrelated to the reason she was admitted so you would still do the reason she was admitted as the principal diagnosis now she was admitted for several different reasons and one of them is most related to the delivery then that's the one you would use first so the guidelines also state code also any complications of the delivery as an additional diagnosis use also a code from category z37 outcome of delivery and we'll talk more about z37 later on in this presentation there are also specific guidelines for cesarean deliveries if the delivery was by cesarean during this admission was first the condition responsible for the admission if the reason for the admission was the same as the reason for the caesarean list that first if the reason for admission was unrelated to the reason for the cesarean list the unrelated condition first this is kind of the same thing we talked about before and not for vaginal deliveries but the separate guidelines for that so i thought i would go ahead and mention them so here's an example maternal patient with diet control gestational diabetes seen at 38 weeks gestation and obstructive labor due to floodling presentation cesarean performed for mal presentation so the cesarean was the reason with the instruction was the reason for the cesarean and the reason she was admitted was abstract she was on labor and it was obstructed cesarean delivery for male presentation so first you're going to list 064.8 xx0 the reason for the admission was the obstruction so this is listed first list then it was code for gestational diabetes oh 24.420 then z3838 for 38 weeks gestation and we'll talk more about that later and see 37 for outcome of delivery and i'll talk about these both of these z codes later on okay code category o09 is used for supervision of high-risk patients this is for conditions that are not complicating the preg this pregnancy at this time but maybe in the future many are history codes so the patient in a previous pregnancy had an ectopic pregnancy a molar pregnancy preterm labor or something like that now they also in this and 0 9 are codes for pregnant patients who are younger or older than usual and more likely to be at risk of a complication so these codes are used only in the antepartum period all of the codes in o09 if the admission is for delivery don't use a supervision code if the patient has a complication you're going to list that but you're not going to list a supervision code because that's only saying we think this there may be a problem you want if there's a complication now then you're going to report that for example a patient may have preterm labor in a previous pregnancy and so you're going to use a code 0 9.21 history of preterm labor during the andy pardon period where she's admitted for pregnancy and that she has preached for delivery and she has pre-term labor then you're going to use 0-6-0 pre-term labor so is it present now or not that is the question so let's look at code categories in the pregnancy chapter code 0 30 to 0 48 are maternal care related to the fetus and amniotic cavity and most importantly for this discussion possible delivery problems these are ones i'm going to focus on if a patient has one of these conditions and delivers this admission use a digit for the trimester since there are no digits for in childbirth so for example a patient may be pregnant in her third trimester and have placenta previa without hemorrhage if delivered this admission use o forty four point three three the fifth digit three indicates third trimester since there's no digit four in child birth um there are also other categories for placental problems o43 o46 for placental problems that may affect delivery many of the conditions listed in these categories may cause obstruction during childhood in these cases use the code for the obstruction instead of a code for these categories for example category o32 is for maternal care for malpresentation of the fetus if during the antipartum period use this code it's important to note that the fetus is not in the position it should be but it's not causing any real problems at this point certainly something to be watched over carefully on the other hand if she's coming in for a delivery and the male presentation is causing instruction you're going to go to code category o64 for obstruction instead of o32 for now presentation so timing is everything now category o42 is a little different the fourth digits are for onset of labor within are not within 24 hours following rupture of the membranes the fifth digits premature mature are full term pregnancy sixth division is trimester so there's no digits for in childbirth so again you're going to use a code for in childbirth descriptions rupture of membrane preterm full-term pregnancy time before labor begins but so assuming that labor so assuming that she's probably going to deliver but there's no digit for in childbirth so complications of labor and delivery are found in categories 0.6077 some of these codes include digits for fetuses some codes include digits for trimester usually that in this case the selling second trimester and third trimester but they don't include digits for in childbirth since these codes are for conditions that occur during labor and delivery that makes sense that there are no digits for in-child birth common assumption that she's going to deliver but there are the trimester digits so category o 60 is used for complications of labor and delivery the codes include preterm labor with and without actually delivering this admission there are dishes for trimester but not for child in childbirth since the fourth digits indicate whether delivery has occurred or not so you can see fourth digit without delivery preterm delivery term delivery so adding a digit for in childbirth would not really add that much information category o 62 is for abnormality of forces of labor there are no digits for trimester fetus or in childbirth and these codes only have four digits so this is abnormality of forces of labor so the contractions may be inadequate maybe uterine inertia precipitous labor which is unusually fast but there's no digits for trimester fetus are in childbirth because she is in labor okay category o63 is for long labor these codes are only four digits and you have you can see here i don't see how well you can read this stage one stage two stage three what happens in that so stage one delayed it's supposed to last 10 to 14 hours two delayed expulsions one to four hours delivery placenta usually five to 15 minutes after delivery and then return to normal so there are also codes for if a patient has multiple fetuses one is delivered and a delivery of the second our third one is delayed so there's that's 063.2 there are only four digits in these codes but there's no digits for trimester fetus are in childbirth categories o64 to o66 are used for obstructed labor note that categories o32 and l33 are used if the patient is not in childbirth at this time so the patie fetus may be in now position but it's not causing obstruction at this point because she's not delivering so we have o64 due to male position and now presentation o65 problems with the mother's um anatomy and then other oh 66 others such as the baby's just too big so if it's before onset of labor you got o3203 if it's um after beginning of labor and it's causing obstructions o64066 again timing so category o67 is used for hemorrhage during labor and delivery again if the patient is not in childbirth at the time use code 046 anti-partum hemorrhage instead so that's listed here this is labor and delivery complicated by hemorrhage this is anti-partum hemorrhage and this is postpartum hemorrhage so timing so there are other code categories that include labor and delivery in the code descriptions but do not have digits for in childbirth so here are some examples o68 includes codes for fetal acidosis acidemia alkalosis complicating labor and delivery this has to do with ph and metabolic complications and these codes are only three digits category o69 includes codes for complications involving umbilical cord the cord may be around the fetus's neck and maybe prolapse may be causing compression these codes include digits for fetus but not for trimester or in childbirth category o70 is used for perineal lacerations during delivery tears during delivery these codes include four digits with the digit for the degree of laceration o71 is used for other obstetric traumas such as rupture of the uterus inversion of the uterus or other injuries o72 is used for postpartum hemorrhage some codes this is included here because some codes describe hemorrhage immediately following delivery so that would be part of the delivery process they also codes for delayed hemorrhage which is defined as 24 hours after delivery often that hemorrhage is due to a retained placenta for example category o73 is used for retaining placenta and other membranes without hemorrhage so this is one is with hemorrhage and this is without hemorrhage um category 074 used for complications anesthesia during labor and delivery now it's interesting that category o29 is used for complications with anesthesia during pregnancy 074 is far during labor and delivery so again timing category 075 is used for other complications of labor and delivery such as maternal distress shock parexia infections categories 0.76 and 077 are used for fetal distress during labor and delivery all of these categories are used during the admission when the delivery occurs now let's move on to diagnosis codes for encounters for our delivery these sound like procedures but they're diagnosis codes you have to have some diagnosis of why is the patient being seen the patient is being seen to deliver so the code that everybody wants is on their pregnancy is oh 80 the perfect uncomplicated delivery minimal no assistance with or without episiotomy without the need for virgin spontaneous cephalic vaginal full term single live born this is delivery we all want but few women actually have it you can use this code if the patient had a complication earlier but it is not present now there's no complication now so how do you find this in the index o 80 is listed under delivery completely normal or delivery uncomplicated so what else do we know about o80 080 is always listed first it has only three digits you can use an additional code to indicate outcome of delivery now the thing to remember students coders are so anxious to just do oh it's an 080 but you have to have all of those things listed before on previous slide present in order to use this if there is any other code that is appropriate to use from chapter 15 on pregnancy then 080 is not the one you want to do if there's anything else you can code from that chapter and that means there's a problem and that means you can't use 080. now code 082 is used for cesarean delivery when there's no documented reason about why a a cesarean rather than a vaginal was necessary so encounter for cesarean delivery without indication why was this cesarean needed we don't know if there's a complication of some sort of instruction that says oh this is why a cesarean was done then you're not going to use this code you're going to use a code for the complication since that's much more specific and again you're going to do a code for outcome of delivery now 090.3 most codes in the cat in this category 090 are complications of the purparam however within this category is a code 090.3 which is used when cardiomyopathy develops as a result of pregnancy and a woman who did not have a pre-existing heart disease now this is peripartum which means the last month of pregnancy to five months after delivery well that period includes delivery right so last month of pregnancy to five months after delivery so you may use um this code if appropriate so other obstetric conditions 0.94 to o9a so this is the last group of diagnosis codes we're going to talk about these codes include digits for pregnancy in childbirth and the purpurea all of these include digits for childbirth so you've got maternal infections 0.98 other internal diseases classified elsewhere but complicating pregnancy child with probirium 0.99 and maternal malignant neoplasms injuries abuse 09a okay so all of these include digits for in childbirth and they all say use an additional code to get more specific well she has some maternal infections well what's the infection so you're going to use another code to provide some more information now kind of talked about this a little bit before but z codes routinely used with delivery so z37 is used when the babies indicate when the baby's life born stillborn and how many babies were there this is baby one of three maybe two of four whatever this code is always listed on maternal delivery records if she delivered during that admission you need a z37 code but it's never listed first okay so how do you find this code it's in outcome of delivery another z code is z3a weeks of gestation if the documentation includes week's gestation at the time of the encounter you should use a z3a code you have you may or may not have a digit for trimester but this gives you a little bit more specific information than just trimester now there are times when you do not use the z3a code don't use the z3a weak suggestion for abortions miscarriages elective terminations and postpartum conditions so where do you find this code look up pregnancy weeks of gestation or you can look up gestation in the index here are some entries in the index that will help you find these codes delivery includes subterms for cesarean completely normal and complicated by you can also look up outcome of delivery to get that z code and you'll probably in in most cases when you do a delivery code you're also going to do a code for some kind of complication something hypertension or something else going on in that case you would go to the pregnancy index the present pres pregnancy main term in the index okay so now let's move on to the icd-10-pcs procedure coding for labor and delivery these fortunately are fairly straightforward obstetric procedures are coded to section one which is obstetrics here the body system the root operations body part now remember for the tricky one of the tricky parts of this is you have sometimes code from the obstetric session section and sometimes for the female reproductive system and i'll talk about when you use the difference okay when one is cedric and one is female so if you're coding with obstetric procedures with section one value if you look in your book it's only three pages it's only 12 tables so you really don't need to go through the index you can just turn to these pages and i'll give you some examples of each of the tables what would be coded there so you can just write that in make it easier on yourself okay so products of conception this is an obstetric and obstetric procedures the body part is products of conception so the products of conception or any structure that developed due to the pregnancy the fetus amniotic membrane umbilical cord fluids whatever so just think did the woman have this tissue before she was pregnant if the answer is yes then you're going to use the female genital system if the answer was no like the fetus then you're going to use the centric section and products of conception so this is what we have we have section one is obstetrics the body system is always pregnancy you have these possible root operations 12 of them and only three possible body parts so this makes it simple the root operations are change drainage abortion extraction delivery insertion inspection removal repair reposition resection and transplantation the body part values are products of conception products of conception retained products of conception at topic so the root operations are drainage extraction delivery insertion and removal these are the ones you'll use for delivery so let's give you some examples of these and this is the kind of thing that you can write in your book and it just makes your life so much simpler if you have it written right there drainage and amniocentesis percutaneous fetal spinal tap artificial rupture of membranes so you're taking out fluids so therefore it is a drainage an extraction is a cesarean delivery forceps delivery vacuum to level delivery so some instruments are used to take um the remove the fetus to birth the baby delivery is manually assisted delivery no instruments vaginal delivery spontaneous abortion insertion is an example is insertion of fetal monitoring device um removal is removal of fatal monitoring device without replacement and reposition is an external cephalic version so if you write these examples in next to the table that will make your life much easier and make it much simpler to find these so let's look at the body part values the body part values are products of conception process conception retained and productive conception ectopics only three possible ones so we already talked a little bit about what products of conceptions means the fetus the membranes the umbilical cord amniotic fluid anything that wasn't there before she was praying i think that developed because of the pregnancy products of conception retained tissues remaining after the delivery such as a retained placenta so she's delivered she has a retained placenta products of conception ectopic that's tissue where the fertilized egg in plants in the fallopian tube or cervix or someplace else instead of within the uterus so the only three possible body parts so for cesareans we said that's that's an extraction because instruments are used the qualifier values are classical low cervical or extra peritoneal it all depends on where the incision was made so those are the difference between those two qualifiers those three qualifier values a forceps delivery also using extraction is there's qualifier values for low forceps mid forceps high forceps and that's where the fetal head is at the time the instruments are used the location of the fetus's head okay so there's the other qualifier values so for vacuum go to extraction qualifier value vacuum internal version the root operation is repositioned and the qualifier value is internal version drainage removal of blood for testing fetal blood and then delivery manual meaning using the hands so let's look at some examples of uh delivery codes for an uncomplicated vaginal delivery use one zero e zero x c z so one for obstetric zero for pregnancy e for delivery zero for products of conception x for external approach z for node device z for no qualifier and you build that and that this is the code you come up with so root operation delivery is used when the delivery is manually assisted only if instruments are used the root operation is extraction so you end up with one zero d zero one for obstetrics zero for pregnancy d for extraction zero for products of conception so for a cesarean delivery it's also coded to extraction one for obstetrics zero for pregnancy d for extraction zero for products of conception zero for open approach since it involves an incision canopy excuse me other procedures can be performed during a pregnancy one of the most common is an episiotomy which is performed open the perineum to assist in the vaginal delivery now the guidelines say repair of an episiotomy is included in the code for the episiotomy so this is code to the surgery section not the obstetric section she had a perineum before she was pregnant okay so therefore it is in the um pregnancy in the female genital system so this is a female genital system division is the rooted operation because you're splitting taking a perineum and you're splitting it and the body part is perineum so repair of lacerations the tears that may occur this is coded to the surgery section also because she had tissues the perineal muscle or the vulva before she became pregnant this is not developed because of the pregnancy if the guidelines say if several lacerations are listed code only the highest degree so if an episiotomy was performed to assist with the delivery but then the episiotomy tears open a little more you can code the laceration repair okay and again this is coded to the surgery section not the obstetric section okay dnc dilation and curettage this can be this could be performed after the delivery to remove the retained placenta the instruments are inserted into the vaginal canal so one for obstetrics d for pregnancy um zero for pregnancy d for extraction one for products of conception retained so this is retained placenta and the placenta developed because of the pregnancy there approach may be natural artificial opening or endoscopic and then z z artificial rupture of membranes this is a drainage since fluid is removed one for obstetrics zero for pregnancy nine for drainage zero for products of conception the approach values will vary so i didn't list those there so when i hope the rest of it however is appropriate okay there is another code that is not another possible procedure that's not reported through female genital or obstetrics and this is administration of pitocin to induce labor so this is a drug administered by infusion into the peripheral vein so in the index if you see introduction of substance inter on products of conception you're referred to the administration section so three for administration e for physiological symptoms and anatomical regions zero introduction three peripheral vein three percutaneous v for hormone and j for other hormones so there's no specific pitocin digit it's just hormone so it is impossible to remember all of these many many guidelines so here are some suggestions of notes you can write in your book to help you remember the guidelines anytime there is something you think oh i'm going to have trouble remembering that write it in your book it makes such a difference you'll look at it six months from now and go oh yeah i remember writing that in i remember it now so it's very helpful so circle the notes in the guidelines for chapter 15 about digits and delivery and sequencing delivery so codes oh thirty oh four eight there are no digits for in childbirth use digit for trimester so just write that in use digit for trimester o67 circle note that any part of hemorrhage is o46 so you need i said timing is everything antepartum or intrapartum look at o80 this is so often misused circle the note that describes cephalic vaginal single i'll circle that all those that description of it and write in all are required you have to meet every single one of those criteria or you can't use it and o82 underline the words without indication so that you remember that you'd go to a complication code if there is an indication for why cesarean had to be done 0.90.3 right in the definition of peripartum last month of pregnancy to five months after delivery and c3a right in mother's chart only a lot of people end up putting that on the babies chart and that is incorrect okay what about the pcs book so write in turn to the pages for um obstetrics right in the definition of products of conception you might also write in a note that about if it's um something that the woman already had go to the female genital system not the obstetric system so next to the table for drainage write in the examples that we talked about amnioces fetal spinal tap fetal blood draw artificial rupture of membrane an extraction the table for extraction right in cesarean four sets vaginal delivery for table for delivery right in vaginal delivery spontaneous abortions and miscarriage on the table for insertion write in insertion fetal monitoring device table for removal writing removal of fetal monitoring device without replacement for table for reposition write in internal version you might also want to write into the definitions of low mid and high forceps the qualifier values and writing the definitions of the different types of sicilian classical low cervical and extraperitoneal let me just write those in your book you don't have to go to the index just turn to those pages it goes okay cecilia that's an extraction and i'll be right there sitting there waiting for you okay that completes this video if you have questions or comments please feel free to contact me i am here um here's again my list of books on amazon one on evaluation management one on cm and one on pcs these are all available on amazon i would appreciate it if you would subscribe let's see my picture down here at the bottom just click on that and you can subscribe to my channel if you'd like on copies of the slides for this video contact me again at the email address thank you so much for listening i hope this was helpful thank you