PDX Selection in OB Records

One of the issues addressed in AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS is PDX selection on obstetrical records and the misinterpretation of the official coding guidelines.

Selection of PDX on Delivery Records

The condition that prompted the admission or main circumstances of admission would be the PDX. The only time that the complication of delivery would be the PDX is if the patient were admitted for routine pregnancy and developed a complication after admission or during delivery. That is because coders cannot report the routine pregnancy code when there is a complication of delivery code assigned.

Examples of PDX selection during delivery:

• Patient presents for delivery at 41 weeks in labor without any pregnancy complications noted. The patient delivers precipitously. In this case, the post-term pregnancy would be the PDX followed by the complication of precipitous delivery. Remember the condition that prompted the admission is assigned as the PDX when a patient is admitted for delivery.
• Patient presents for delivery at 39 weeks in active labor. She suffers a third-degree perineal laceration, which is repaired. She developed preeclampsia early in the pregnancy and was monitored closely throughout. In this case, delivery complicated by preeclampsia is the PDX followed by a code for the perineal laceration.
• Patient presents in active labor. There are no complications noted during this pregnancy. During delivery, the patient suffers a periurethral tear. In this case, the PDX is the complication of the periurethral tear since there were no other pregnancy complications.
• Patient presents for delivery from the ED. She has a history of hypothyroidism, and this is well controlled on Synthroid. Before delivery, the patient developed a sudden decrease in blood pressure. This was monitored and treated with additional IVF. The baby was delivered without any other complications. In this case, the PDX is the pregnancy complicated by hypothyroidism. Remember it is the physician’s responsibility to documented that a condition being treated is not affecting the pregnancy. 

This was not a change from the official guidelines but a clarification of the guidelines for reporting PDX on OB records.

Authored by Kim Boy, RHIT, CDIP, CCS, CCS-P

References:
AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS
ICD-10-CM Official Guidelines for Coding and Reporting FY 2016 Page 53

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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.