ICD-10-CM Specific Coding Guidelines - Pregnancy Part II

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now I want to kind of speed things up

just a bit and I want to take you to a

quick discussion on coding

for

deliveries just icd1 CM coding for

deliveries all

right there are some specific guidelines

that I want to um bring to your

attention guidelin C15 B3 when a patient

is admitted for a pregnancy complication

and there's no

delivery you're going to code that

complication as the reason for the

encounter say a patient has um

pre-eclampsia and they're admitted into

the hospital and they don't give birth

of course pre-eclampsia will be your

first listed or your principal diagnosis

all right guidelin C15 B4 when a

delivery

occurs if a patient delivers via

C-section the circumstance that

necessitated the C-section should be

sequenced first that's anything any type

of delivery when a delivery occurs the

circumstance that necessitated the

delivery will be sequenced first

and I also want to let you

know C15 N1 and C15

N2 when there is an

uncomplicated or resolved complication

and the outcome of delivery is normal

you're going to sequence 080 normal

delivery first followed by your single

live birth code that just tells and this

is for the mom's record only and this

just tells you the the um type of

delivery the type of

delivery and it's only on the mother's

record and don't confuse it with

z38.00 don't confuse it with that now

just so you know

episiotomies they're considered

normal yeah they're just making a little

slit into the perineum so that's pretty

common all right this is how you code an

obstetrical case and I'm going to just

show you um and you can do the next one

on your own all right Miss Stephanie

please and thank

you thank you Miss J

a080

082 z3a

38 z37.0

b80 z38 38

z38.00 C

0882 Z3

a.38

z38.00

d8 Z3

a.38 and z37.0 a 38 year a 38 weeks

pregnant patient presents to the

hospital and full labor the patient was

experiencing contractions every one to

two minutes one hour after arrival the

contraction ceased the patient's

obstetric Dr Thompson arrives to the

hospital examines the patient then makes

the decision to carry out an an an

amniotomy the patient began delivering

the infant shortly after the physician

insided the perum to enlarge the vaginal

opening to accommodate the delivery the

patient had a normal spontaneous

delivery of a single live birth with no

complications the patient and baby were

admitted treat treatment for the next

two days what are the icd1 CM codes for

this encounter your time begins

now thank you so much I don't think this

is one that has a time because I'm

supposed to walk you through it and if I

asked her to read it so that you if you

want to attempt to answer and some of

you have a way to go outstanding all

right so this is what I'm going to do

and if you look at the answers they're

only um icd10 CM so there are no

procedures that we're coding for so I'm

only going to highlight in yellow my

diagnosis all right so we have a 30

weeks pregnant patient we have a normal

spontaneous delivery and single life

birth with no complications and in green

I'll put the procedures just so that you

know we have

amniotomy ins sized the perineum so they

they um broke the water and They carried

out an

otomy and they had a delivery they um

helped the mom deliver the baby so we're

going to code for the normal delivery if

we determine that this is normal and a

single live bir birth and this is a 30

weeks

gestation all right I'm going to go to

my guideline normal delivery

uncomplicated C15 And1 I believe it's

uncomplicated there are

no complications mentioned we can code

an

otomy and that's um inzing the perineum

in this case the perineum was in sized

and and look at the guideline in the

right hand column it says with or

without

otomy and we're going to sequence 080

followed by the single live birth code

so I'm

looking all right I do see the week's

gestation that's appropriate too but I

would probably sequence that last all

right so we're going to get rid of a

because it's coding for

080 and this 082

this 082 is actually cesarian section so

I'm going to get rid of

it right you're only going to use

1080 or

082 all right so A and C have to

go and we can eliminate something else

on site but I'll let you see this in a

moment all right so the difference

between B and D r b is coding for

z38.00 this is a liveborn infant code

and this only goes on the infant's

record not the mother's record and if

you go to the subcategory it says this

category is for use as the principle

code on the initial record of a newborn

baby okay I'm going to let Mr sand talk

more about that but

z38.00 is a principal diagnosis code and

it should be on the Infant record so it

is incorrect because they're trying to

code it on the mother's

record and

z38.00 single liveborn infant delivered

vaginally not

correct and

Z37 is is correct it is the outcome of

delivery code and if you look at the

notes underneath if you confuse the two

you might want to write mother's record

only and next to

z38.00 infants record but underneath it

says this category is intended for use

as an additional code so you don't

sequence in first to identify the

outcome of delivery on the mother's

record it is not for the newborn record

so this is our outcome of delivery z37.0

single live

birth all right so

z30 z37.0 this is the mother's record it

is the outcome of

delivery

and it

is um only on the mother's

record and it

explains the type of birth is it single

or multiple births only on the mother's

record Z3 8.0 Z this is the infant

record this is a single live born code

for the infant only on the infants

record it is principle you have to

sequence this first if it's this is the

first record for that infant and this

explains how the baby was born vaginal

or cesarian and the location where was P

baby in the hospital at home in the cab

Etc now this is how you code for

deliveries pretty

much I don't know how my see um all

right but there's something else I want

to tell you whenever you're coding for

deliveries and you have

multiple um pregnancy

complications the code code that best