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ICD-10 Clinical Scenarios for OBGYN

Quality clinical documentation is essential for communicating the intent of an encounter, confirming medical necessity, and providing detail to support ICD-10 code selection. In support of this objective, we have provided outpatient focused scenarios to illustrate specific ICD-10 documentation and coding nuances related to your specialty.The following scenarios were natively coded in ICD-10-CM and ICD-9-CM. As patient history and circumstances will vary, these brief scenarios are illustrative in nature and should not be strictly interpreted or used as documentation and coding guidelines. Each scenario is selectively coded to highlight specific topics; therefore, only a subset of the relevant codes are presented.

The clinical concepts for OBGYN guide includes common ICD-10 codes, clinical documentation tips and clinical scenarios.

Scenario 1: Abdominal Pain & Ovarian Cyst

Scenario Details

Chief Complaint

  • Abdominal pain that will not go away and irregular menses.

History

  • 21 year old female G2P1001 with RLQ abdominal pain1 for the last 6 months. Pain is a dull ache.
  • Reports 2 periods in the last year. Historically cycles have been regular lasting 28 – 30 days each. LMP was 4 months ago.
  • No family history of ovarian or cervical cancer.
  • Patient had a benign ovarian cyst successfully removed at age 172.

Exam

  • Abdomen is soft. RLQ is tender to palpation. No rebound tenderness or guarding of abdomen. Bowel sounds normal in all 4 quadrants.
  • Pelvic shows cervical motion tenderness and adnexal tenderness on the right.
  • Mild right ovarian tenderness. No palpable ovarian or uterine enlargement.
  • Urine pregnancy test is negative.

Assessment and Plan

  • Given patient history and clinical findings right ovarian cyst is suspected.
  • Order transvaginal ultrasound to rule out ovarian cyst.
  • Patient counseled on pain relief exercises. Pain Rx also given.
  • Scheduled a follow-up visit in 1 week.

Summary of ICD-10-CM Impacts

Clinical Documentation

  1. There are separate ICD-10-CM codes for each quadrant of the abdomen when describing pain. This information needs to be captured in the note. Providing a detailed description of the pain characteristics is important as well. The documentation and context of the pain presentation will determine if additional
    codes are assigned, that is, if the pain is considered part of the disease process, an additional code for pain will not be listed. To address this point in the coding section we have presented both combinations (N94.89 Other specified conditions associated with female genital organs and menstrual cycle OR N92.5 Other specified irregular menstruation AND R10.31 Pain localized to other parts of lower abdomen, right lower quadrant pain).
  2. It is important to include the patient history, as this can justify additional diagnostic testing.
  3. In ICD-10-CM abdominal tenderness is differentiated to address the rebound characteristic with different codes.

ICD-9-CM Diagnosis Codes

629.89 OR Other specified disorders of female genital organs
626.4 Irregular menstrual cycle
789.03 Abdominal pain, right lower quadrant
789.63 Abdominal tenderness, right lower quadrant
V13.29 Personal history of other genital system and obstetric disorders

ICD-10-CM Diagnosis Codes

N94.89 OR Other specified conditions associated with female genital organs and menstrual cycle
N92.5 Other irregular menstruation
R10.31 Pain localized to other parts of lower abdomen, right lower quadrant pain
R10.813 Right lower quadrant abdominal tenderness
Z87.42 Personal history of other diseases of the female genital tract

Other Impacts

  • Identifying the specific area of abdominal pain is important, as some payers may deny claims with “unspecified” codes.
  • Providing the patient history can justify additional diagnostic tests (such as the ultrasound here).

Scenario 2: Breast Lump/Annual Well Woman Exam

Scenario Details

Chief Complaint

  • “I’ve found a lump on my left breast and I need my annual GYN exam.”

History

  • 47 year old perimenopausal female. G3P3003. LMP December 20, 2013. Last Pap was normal.
  • No history of STD. No family history of ovarian or cervical cancer. No significant changes over the last year.
  • Positive family history for breast cancer – mother and all three sisters. Sisters are BRCA.
  • Reports finding a small lump in left breast.

Exam

  • Pelvic exam is normal. Pap smear performed.
  • Left breast examined normal except for 1.5cm mass on left lower/outer quadrant5. Mass is tender, easily moveable, firm to touch. Axilla normal, without palpable nodes.
  • Right breast normal.

Assessment and Plan

  • Normal pelvic exam. Will confirm Pap results with the patient.
  • Scheduled fine needle aspiration of left breast mass at the end of this week – with Dr. Smith.
  • Scheduled a follow-up visit in 1 week to discuss aspiration results and next steps.

Summary of ICD-10-CM Impacts

Clinical Documentation

  1. Note whether the encounter is for a specific issue or an annual or “general” exam. There are different diagnosis codes for each. The use of the best code may vary by payor according to what services were rendered and the insurance plan’s reimbursement of a well women annual visit versus reimbursement of pelvic and/or clinical breast examinations. As per American Congress of Obstetricians and Gynecologists’ guidelines, a well women exam includes both a pelvic exam as well as a clinical breast examination. The rationale for abnormal findings in this encounter is based on the presence of the breast lump.
  2. Using ICD-9 codes, Pap smear coding may vary by payor. In some cases payors reimburse for the retrieval of the Pap smear by the physician, and the screening Pap smear at a specific frequency (e.g., every 2 years). With the new terminology associated with ICD-10-CM codes this point will need to be assessed and confirmed so correct code assignment can occur.
  3. Like ICD-9, family history can be captured in ICD-10-CM. Capture that information as appropriate in your note. As there is a positive family history for breast cancer denoted with the three sisters identified as BRCA positive, the documentation supports the patient’s susceptibility to a malignancy of the breast.
  4. ICD-10-CM can now capture the side of the body. There are separate codes for left and right breast diagnoses. As the clinical status for this patient is not known, it does not have right versus left, e.g. solitary cyst of left breast.
  5. It is important to describe the mass in as much detail as possible. Even though it is not possible to definitively diagnose the mass at this visit, the provider can code for symptoms and justify referral & subsequent treatment.

ICD-9-CM Diagnosis Codes

611.72 Lump or mass in breast
V72.31 Routine gynecologic exam, with or without pap test
V76.2 Routine screening pap test, intact cervix
V84.01 Genetic susceptibility, malignant neoplasm breast

ICD-10-CM Diagnosis Codes

N63 Unspecified lump in breast, which includes: nodule(s) NOS in breast
Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings
Z15.01 Genetic susceptibility to malignant neoplasm of breast

Other Impacts

  • Providing the patient history can justify additional diagnostic tests based on the patient’s risk (such as the fine needle aspiration).
  • Capturing the appropriate side of the body is important, as some payers may deny claims without this information.

Scenario 3: Preeclampsia

Scenario Details

Chief Complaint

  • Headache, nausea and vomiting x 2 over last 48 hours.

History

  • 32 year nulliparous female well known to me presents today at 36 2/72 weeks gestational age for a scheduled prenatal visit. Long time history migraine headaches. In this pregnancy her BPs are ranging from 125/85 to 135/90 at previous prenatal visits. Over the past 2 days she has not been able to perform usual activities due to her symptoms.
  • Reports continued fetal movement, no contractions, and no vaginal bleeding. Having her typical migraine now. Denies dizziness, LOC, tremors, seizures, epigastric or abdominal pain, muscle weakness/pain, malaise, drowsiness, pelvic cramping, dysuria, hematuria.
  • Medical history and review of systems – migraines with many triggers including hormonal changes, stress, and specific foods, otherwise no changes since last prenatal visit.
  • LMP: August 2013.
  • Diet and exercise: Vegan. On iron supplementation. Moderate activity 3-5 days per week.
  • Allergies: sulfa drugs, penicillin (anaphylaxis noted).
  • Denies tobacco, alcohol, or drug use.
  • Pertinent Labs: U/A 2+ proteinuria +2 glucose.
  • Family history: Mother and father living. Five siblings, four living. Family history positive for hypertension, migraines.

Exam

  • Vital Signs: BP 150/90, T 99.6°F, P 100, R 30. Wt: 157 lb., up 2 lb. from 2 weeks ago.
  • Well nourished, well-groomed, A&Ox3, mood and affect calm.
  • HEENT & Neck: Normal to exam.
  • Respiratory: Lungs clear to auscultation. Chest examination unremarkable.
  • Cardiac: S1/S2, no S3/S4, no murmurs. Rhythm is regular.
  • Abdomen: Fundal height consistent with 36 weeks, single fetus, vertex and engaged; fetal weight ~ 3,000g, FHR 142 bpm.
  • Musculoskeletal: Adequate muscle tone + full AROM x4. Deep tendon reflexes were 4+/4+ with sustained knee and ankle clonus.
  • Extremities: Generalized edema present, 2+ bilateral edema LE. No cyanosis.
  • Vaginal exam: Cervix fingertip dilated and 75% effaced. The vertex was presenting at 0 station. Membranes intact.

Assessment and Plan

  • Preeclampsia.
  • Direct admit patient to Labor and Delivery unit to monitor for worsening preeclampsia or preeclampsia complications.
  • Admission orders: called and faxed to L&D unit nurse.
  • Explained treatment plan and purpose for admission to patient and husband. EMS unit requested and will transport to hospital.

Clinical Documentation

  1. Similarly to ICD-9, ICD-10 describes preeclampsia as a complication of pregnancy which is characterized by hypertension; proteinuria and edema may also be present. ICD-10 differentiates from ICD-9 in clinical terminology to describe preeclampsia as mild to moderate, severe, or unspecified. Eclampsia is when seizures are associated with the preeclampsia condition. The HELLP syndrome is characterized as severe preeclampsia with hemolysis, elevated liver enzymes, and low platelet count.
  2. ICD-10 increases the alternatives for hypertensive disorders in pregnancy (with or without the presence of proteinuria and/or edema); refer to an official ICD-10 guide for example alternatives.
  3. ICD-10 provides distinct coding options for the life-threatening HELLP syndrome to be coded as both a variant or complication of preeclampsia or eclampsia. Coding options also are sensitive to timing of these conditions, reflecting that preeclampsia, eclampsia, and HELLP usually occur during the second or third
    trimesters of pregnancy, or sometimes after childbirth.
  4. The American College of Obstetricians and Gynecologists (ACOG) published a practice guideline for pregnancy induced hypertension in 2013 which includes a revision of the criteria for preeclampsia. In this scenario, we applied the ACOG guideline and are not coding the patient’s symptoms as they are considered
    integral to the disease process and her underlying medical condition. Also note that per ACOG guidelines, preeclampsia is no longer identified as mild, moderate, or severe, rather it is preeclampsia or preeclampsia with severe features. The new ACOG guidelines are not currently reflected in ICD-10 and therefore the previous criteria of mild, moderate and severe remains. ICD-10 codes to support ACOG guidelines will not be changed within the code set until after national implementation. In the absence of severe features, the options for codes are mild to moderate or unspecified. The ACOG guidelines document can be accessed at: www.acog.org/Resources_And_Publications/Task_Force_and_Work_Group_Reports/Hypertension_in_Pregnancy

ICD-9-CM Diagnosis Codes

642.43 Mild or unspecified preeclampsia, antepartum condition or complication
648.93 Pregnancy complicated by conditions classified elsewhere, antepartum
346.90 Migraine, w/o mention of intractable or status migrainosus

ICD-10-CM Diagnosis Codes

O14.Ø3 Mild to moderate preeclampsia, third trimester
O99.89 Pregnancy, complicated by disorder of specified body system
G43.9Ø9 Migraine, unspecified, not intractable w/o status migrainosus
Z3A.36 36 weeks gestation

Other Impacts
No specific impact noted.

Scenario 4: Bacterial Vaginosis

Scenario Details

Chief Complaint

  • Vaginal discharge with odor x 1 week.

History

  • 28 year female, established patient, presents complaining of a thin, grayish-white vaginal discharge with a noticeable fishy smell accompanied by vulvar itching. She first noticed symptoms about 1 ½ weeks ago. Patient states she tried to self-treat using an over-the-counter yeast preparation approximately 1 week ago without relief of symptoms. She denies any history of similar symptoms in the past.
  • LMP: occurred 2 weeks ago, normal cycle for her. Last PAP exam 8 months ago, normal. No previous mammograms.
  • Social history: Physically active. She is in a new monogamous relationship with male partner x 5 weeks, sexually active with protection. Denies history of STIs. Admits to frequent douching and bubble baths.
  • Immunizations: not immunized for HPV.
  • No tobacco, alcohol, or other drug use.
  • Review of systems negative except as noted above.

Exam

  • Vital Signs: BP 128/64, T 98.7°F, Ht. 63 in. Wt. 108 lbs.
  • Well-groomed, A&Ox3.
  • Pelvic: External exam-vulvar redness, no vulvar edema and no adherent white clumps present; Speculum exam – vaginal walls pink, cervix intact, closed os, thin gray and foul smelling discharge noted in vaginal canal. Swab specimen obtained for microscopy exam. Bimanual exam – no pelvic tenderness, uterus smooth, uterus and adnexa are normal in size, ovaries not palpable.
  • Labs in office: Urine hCG – Negative; wet prep – Positive whiff test, clue cells and leukocytes present; negative for yeast; vaginal pH elevated.
  • Bacterial vaginosis.
  • Prescribed 7-day metronidazole.
  • Discussed and administered HPV vaccine in office today.
  • Provided vaginal hygiene pamphlet. Instructed patient to avoid douching and use of bubble bath products. Refrain from intercourse for one week after starting
    metronidazole. Other activities as normal.

Clinical Documentation

  1. Vaginitis is one of the most common gynecologic conditions encountered in the physician office setting.
  2. ICD-10-CM provides four alternative choices that map to the ICD-9 code 616.10 Vaginitis and vulvovagi nitis, unspecified. The four options are N76.0 Acute vaginitis; N76.1 Subacute and chronic vaginitis; N76.2 Acute vulvitis; and N76.3 Subacute and chronic vulvitis. As there is no indication of previous episodes
    and/or ongoing care, acute vaginitis is selected.
  3. Bacterial vaginosis is not usually associated with soreness, itching or irritation, therefore it is coded separately.
  4. In the scenario above for this patient with bacterial vaginosis, refraining from intercourse was recommended by this physician. To clarify, bacterial vaginosis is not considered an STI and physician recommendations for abstaining from sexual activity varies from physician to physician.
  5. This note intentionally does not include a discussion of STIs or reproductive planning which would be commonly denoted in the evaluation and counseling of a female of this age.
  6. ICD-9-CM includes a variety of vaccination codes while ICD-10-CM offers only one generic immunization code.

ICD-9-CM Diagnosis Codes
616.10 Vaginitis and vulvovaginitis, unspecified
698.1 Pruritis, vulvar
V04.89 Need for prophylactic vaccination and inoculation against other viral diseases

Other Impacts

Index to Diseases for ICD-9-CM under the word itching states “see also Pruritis”. Under Pruritis, vulvar that codes to 698.1

ICD-9-CM has a variety of vaccination codes

ICD-10-CM Diagnosis Codes

N76.Ø Acute vaginitis
L29.2 Vulvar, pruritis
Z23 Encounter for immunization

Other Impacts

Index to Diseases for ICD-10-CM under the word itching states “see also Pruritis”. Under Pruritis, vulvar that codes to L29.2

ICD-10-CM Has only one generic immunization code