Helpful Tidbits for Coding OB Records (Chapter 15 in ICD-10-CM)
- Multiple codes may be needed to report conditions in a pregnancy patient
- Sepsis due to post procedural obstetric surgical wound would be coded with a code from Chapter 15 first, followed by the specific infection
- Chapter 15 codes have sequencing priority over the general coding guidelines
- Additional codes should be reported to fully document the condition affecting the pregnancy, delivery, or the puerperium
- If there is an “in childbirth” option for the Chapter 15 code, this would be assigned when delivery occurs instead of the trimester of the pregnancy
- If the patient is admitted to the hospital during one trimester and then discharged after entering a subsequent trimester, the trimester when the condition developed would be selected and NOT the trimester at the time of discharge
- The PDX is the main circumstance or complication of the pregnancy which necessitated the encounter when no delivery occurs
- When delivery does occur, the PDX is the condition that prompted the admission. If there are multiple conditions that prompted the admission, sequence the one that is most related to the delivery as the PDX
- If the patient is admitted for delivery without any conditions or complications (NSVD is expected), but develops a complication of delivery (such as perineal laceration during delivery), the PDX would be the perineal laceration
- Complications of delivery would be assigned as additional diagnoses
- If cesarean delivery is necessary-if the admission is for a condition that resulted in the need for cesarean this condition would be sequenced as the PDX. If the reason for the admission is unrelated to the need for the cesarean delivery, the condition that prompted the admission should be selected as the principal diagnosis
- Peripartum timeframe: Peripartum is defined as the last month of pregnancy to five months postpartum.
- Postpartum timeframe: Postpartum begins immediately after delivery and continues for six weeks post-delivery
- A postpartum complication is ANY condition occurring within the six weeks period (Chapter 15 codes can also be used longer than the peripartum/postpartum timeframes when the provider documents that the condition is pregnancy related.) One example is a patient that has cardiomyopathy related to pregnancy that is still ongoing after the timeframes. If physician documentation supports that the cardiomyopathy is related to the pregnancy it should be coded as a complication regardless of the length of time.
- Supervision of high-risk pregnancy are intended for use only during the prenatal period
- If there are no complications of labor and delivery ICD-10-CM code O80 would be reported
- BMI is not reported on pregnancy records
There are multiple examples in the Coding Clinics referenced below.
ICD-10-CM Official Guidelines for Coding and Reporting FY 2019
ICD-10-CM/PCS Coding Clinic®, Fourth Quarter 2016 Pages: 125-126 and 150
ICD-10-CM/PCS Coding Clinic®, First Quarter 2016 Pages: 3-6
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.