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ICD-10 Tips for OBGYN

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

Specifying anatomical location and laterality required by ICD-10 is easier than you think.

This detail reflects how physicians and clinicians communicate and to what they pay attention. It is a matter of ensuring the information is captured in your documentation.

In ICD-10-CM, there are three main categories of changes:

  • Definition Changes
  • Terminology Differences
  • Increased Specificity

For OBGYN, the focus is increased specificity and documenting the downstream effects of the patient’s condition

TRIMESTER

Definition Change

Documentation of trimester is required. Determination is calculated from first day of last menstrual period, and is documented in weeks.

The definitions of trimesters are:

  1. First Trimester – Less than 14 weeks, 0 days
  2. Second Trimester – 14 weeks, 0 days through 27 weeks and 6 days
  3. Third Trimester – 28 weeks through delivery

Spotting

ICD-10 Code Examples

O26.851 Spotting complicating pregnancy, first trimester
O26.852 Spotting complicating pregnancy, second trimester
O26.853 Spotting complicating pregnancy, third trimester
O26.859 Spotting complicating pregnancy, unspecified trimester

VOMITING

Definition Change

The time frame for differentiating early and late vomiting in pregnancy has been changed from 22 to 20 weeks.

ICD-10 Code Examples

O21.0 Mild hyperemesis gravidum
O21.2 Late vomiting of pregnancy

ABORTION

Definiton Change

The timeframe for a missed abortion (vs. fetal death) has changed from 22 to 20 weeks. In ICD-10-CM, an elective abortion is now described as an elective termination of pregnancy.

There are four spontaneous abortion definitions in ICD-10; use the appropriate definition in your documentation:

  1. Missed Abortion – No bleeding, os closed
  2. Threatened Abortion – Bleeding, os closed
  3. Incomplete Abortion – Bleeding, os open, products of conception (POC) are extruding
  4. Complete Abortion – Possible bleeding or spotting, os closed, all POC expelled

ICD-10 Code Examples

O02.1 Missed abortion
O36.4XX1 Maternal care for intrauterine death, fetus 1
Z33.2 Encounter for elective termination of pregnancy

CHILDBIRTH AND PUERPERIUM DISTINCT FROM TRIMESTER

Terminology Difference

ICD-10 allows for the description of “pregnancy”, “childbirth” and “puerperium” as distinct concepts from “trimester.”

ICD-10 Code Examples

O99.351 Diseases of the nervous system complicating pregnancy, first trimester
O99.352 Diseases of the nervous system complicating the pregnancy, second trimester

INTENT OF ENCOUNTER

Increased Specificity

When documenting intent of encounter, include the following:
1. Type of Encounter – e.g. OB or GYN, contraception management, postpartum care 2. Complications – Note any abnormal findings with examination

ICD-10 Code Examples

Z30.011 Encounter for initial prescription of contraceptive pills
Z31.82 Encounter for Rh incompatibility status
Z39.1 Encounter for care and examination of lactating mother

COMPLICATIONS OF PREGNANCY

Increased Specificity

Documentation of conditions/complications of pregnancy will need to distinguish between pre-existing conditions, or pregnancy-related conditions.

When documenting well child exams and screen, include the following:
1. Condition Detail – Was the condition pre-existing (i.e. present before pregnancy) 2. Trimester – When did the pregnancy-related condition develop? 3. Casual Relationship – Establish the relationship between the pregnancy and the complication (i.e. preeclampsia)

ICD-10 Code Examples

O99.011 Anemia complicating pregnancy, first trimester
O13.2 Gestational [pregnancy-induced] hypertension without significant proteinuria, second trimester
O24.012 Pre-existing diabetes mellitus, type 1, in pregnancy, second trimester

ALCOHOL USE, SUBSTANCE ABUSE, AND TOBACCO DEPENDENCE

Increased Specificity

Documentation should capture the mother’s use (or non-use) of tobacco, alcohol and substance abuse along with the associated risk to the child.

A secondary code from category F17, nicotine dependence or Z72.0, tobacco use should also be assigned when codes associated with category O99.33, smoking (tobacco) complicating pregnancy are used. In a similar manner, a secondary code from category F10, alcohol related disorders, should also be assigned when codes under category O99.31, Alcohol use complicating pregnancy, are used.

ICD-10 Code Examples

O99.311 Alcohol use complicating pregnancy, first trimester
O99.331 Smoking (tobacco) complicating pregnancy, first trimester
O35.4XX1 Maternal care for (suspected) damage to fetus from alcohol, fetus