ICD-10-CM CHAPTER 18 – Flashcards
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what letter do codes begin with?
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O
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what record do we use O codes in?
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MATERNAL
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up to less than 14 weeks
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1st trimester
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14 weeks to 28 weeks
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2nd trimester
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28 weeks-delivery
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3rd trimester
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what character indicates trimester? should be based on the provider's documentation of the trimester (or number of weeks) for the current admission/encounter.
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final
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whenever delivery occurs during the current admission, and there is an "in childbirth" option for the obstetric complication being coded, what code should be assigned?
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"in childbirth"
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if women has complication at the end of 2nd trimester but is discharged 3rd trimester, which trimester do you code for?
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2nd
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if patient is admitted for a condition that develops in one trimester and is discharged in another trimester, which trimester do you code for?
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trimester condition developed, NOT trimester of discharge.
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pregnancy incidental to encounter. states patient is pregnant and condition being treated is not affecting the pregnancy.
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Z33.1
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identifies week of gestation. coded on every chart.
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Z3A
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outcome of delivery. should be included on every maternal record when a delivery has occurred. identify the status of the infant, single, twin or other multiple births, and whether the infant was liveborn or stillborn. **ALWAYS ADDITIONAL DIAGNOSIS CODE**
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Z37
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code for routine outpatient prenatal visits when no complications are present.
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Z34
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always have to code what code first?
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O code
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pregnancy occurs anywhere but uterus. fourth digit identifies the site: abdominal, tubal, ovarian, other
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ectopic pregnancy
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early fetal death before completion of 20 weeks of gestation with retention of dead fetus
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missed abortion
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expulsion or extraction from the uterus of all or part of the products of conception: a embryo or a nonviable fetus weighing less than 500 grams. COMPLETE VS INCOMPLETE
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Spontaneous abortion
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expulsion of all of the products of conception from the uterus prior to the episode of care.
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complete abortion
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expulsion of some, but not all, of the products of conception from the uterus.
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incomplete abortion
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elderly pregnant females (35+) young pregnant females (younger than 16)
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O09.5-.6
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codes used when a complication occurs after the abortion itself was completed during a previous admission. **these codes are not used during an encounter for ELECTIVE termination of pregnancy that is uncomplicated or during an encounter when a FAILED ATTEMPTED termination of pregnancy occurs** 4th digit identifies the specific complication
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complications following induced termination of pregnancy (O04)
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codes used when attempted abortion fails and pregnancy continues. may not produce any complication. 4th digit identifies when complication occurs. **NOT USED DURING AN ENCOUNTER FOR TREATMENT OF AN INCOMPLETE SPONTANEOUS ABORTIONS)
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failed attempted termination of pregnancy (O07)
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codes to identify women who are beyond 40 completed weeks of gestation. not considered prolonged until 42 weeks
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late pregnancy (048)
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codes used when a complication occurs with an ectopic and molar pregnancy. **USED WHEN CATEGORIES O00-O02 to IDENTIFY ANY ASSOCIATED COMPLICATION WITH SPECIFIC CONDITIONS INCLUDED IN FOURT DIGIT LEVEL OF O08**
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complications following ectopic and molar pregnancy (O08)
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codes may be used as principal, first listed or an additional diagnosis code. for routine prenatal outpatient visits for patients with high risk pregnancies. 6th character identifies the trimester of pregnancy when supervision occurred
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supervision of high risk pregnancy (O09)
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characterized by bleeding of intrauterine origin before the 20th completed week of gestation, without expulsion of the products of conception and without dilation of the cervix. LOSS OF PREGNANCY IS PREVENTED AND THE PATIENT REMAINS PREGNANT AT THE END OF ADMISSION OR ENCOUNTER
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threatened abortion (O20.0)
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known as habitual or recurrent abortion. defines the spontaneous expulsion of a dead or nonviable fetus in two or more pregnancies at any gestational age.
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recurrent pregnancy loss (O26.20-O26.23, N96)
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used if the current hospital admission or encounter does not involve a pregnancy (in the patient) but rather care of a nonpregnant woman with a history of recurrent pregnancy loss.
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N96
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state of a female after conception until birth (deliver) of the child
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pregnancy
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before 37 completed weeks, but at least 20 completed weeks
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preterm delivery
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between 38-40 completed weeks
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term delivery
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between 41 and 42 completed weeks
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post term delivery
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advanced beyond 42 completed weeks
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prolonged
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when does postpartum or puerperium period begin?
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immediately after delivery and continues for 6 weeks
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Edema, proteinuria and hypertensive disorders Maternal care related to fetus and amniotic cavity Complications of labor and delivery Complications predominantly related to the puerperium
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examples of pregnancy complications
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includes any condition in (I10) specified as the reason for obstetric care during pregnancy, childbirth, or the puerperium.
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preexisting hypertension (O10.0)
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Puerperal sepsis, should be assigned with a secondary code to identify the _____________.
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casual organism
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tobacco use during pregnancy code O99.33 should be coded along with secondary code ______ to identify the type of nicotine dependence.
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F17 Z72.0
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alcohol use during pregnancy code O99.31 should be coded along with secondary code ____ to identify manifestations of the alcohol use.
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F10
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includes any condition in (I15) specified as a reason for obstetric care during pregnancy, childbirth, or the puerperium. **use additional code from I15 to ID the type of secondary hypertension** FURTHER SUBDIVIDIED BASED UPON TRIMESTER ,CHILDBIRTH, OR PUERPERIUM
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preexisting secondary hypertension (O10.4)
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includes any condition in (I11) specified as a reason for obstetric care during pregnancy, childbirth, or the puerperium. **use additional code from I11 to identify the type of hypertensive heart disease
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preexisting hypertensive heart disease (O10.1-)
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includes any condition in I12 specified as a reason for obstetric care during pregnancy, childbirth, or the puerperium. **use an additional code from I12 to identify the type of hypertensive chronic kidney disease
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preexisting hypertensive chronic kidney disease (O12.2-)
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includes any condition in I13 specified as a reason for obstetric care during pregnancy, childbirth, or the puerperium. **use an additional code from I13 to identify the type of hypertensive heart and chronic kidney disease
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preexisting hypertensive heart and chronic kidney disease (O10.3-)
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refers to hypertension with an onset in the latter part of pregnancy without any other features of pre-eclampsia and followed by normalization of the blood pressure postpartum.
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gestational hypertension
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high blood pressure (140/90 higher) protein in the urine
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pre-eclampsia (O14)
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life threatening complication of pregnancy, results when a pregnant woman, previously diagnosed with pre-eclampsia develops seizure or coma. *severe headache* *blurred or double vision* *seeing spots*
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eclampsia (O15.-)
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excessing vomiting
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hyperemesis
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severe morning sickness *mild *with metabolic disturbance *late vomiting of pregnancy *vomiting of pregnancy, unspecified
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hyperemesis gravidarum
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UTIs: one of the most common bacterial infections during pregnancy *associated with risks to both the fetus and the mother, which include pyelonephritis, preterm birth, low birth weight, and increased perinatal mortality. **BASED ON SITE AND TRIMESTER** **USED ADDITIONAL CODE TO IDENTIFY THE ORGANISM**
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genitourinary tract infections (O23)
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increased risk for having a big baby, baby who has hypoglycemia and a baby who has jaundice
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preexisting diabetes (O24)
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what are preexisting diabetes broken down by?
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type of diabetes time of occurrence
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starts when the body is not able to make and use all the insulin it needs for pregnancy. without enough insulin, glucose cannot leave the blood and be changed to energy.
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gestational diabetes
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if patient with gestational diabetes is treated with both diet-controlled and insulin-controlled, only the code for what is required?
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insulin-controlled
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twins, triplets, quadruplets
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multiple gestation (O30)
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what category is used for complications specific to multiple gestations?
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O31
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twins who share the same placenta
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monochorionic
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twins who develop in separate sacs. all fraternal twins are dichorionic
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dichorionic
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identical twins who did not fully separate from one another and are still partially united
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conjoined twins
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what character is used to identify the specific fetus when a complication occurs.
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7th
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O14.- O30.- Z3A-
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coding pre-eclampsia, stated trimester, single, twins, etc; weeks of gestation
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depressed fetal heart tones, fetal bradycardia, fetal heart rate decelerations, fetal heart rate irregularity, fetal heart rate abnormal variability, non-reassuring fetal heart rate or rhythm.
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abnormalities in fetal heart rate and rhythm (O76)
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normal delivery: full term, healthy, single, liveborn infant, no antepartum complications, no complications during delivery, no complications after delivery, heart first position, vaginal, with or without episiotomy, without fetal manipulation or instrumentation. **MUST BE ACCOMPONIED BY A DELIVERY CODE** **USE ADDITIONAL CODE TO INDICATE THE OUTCOME OF DELIVERY** (NO OTHER O CODES CAN BE ASSIGNED WITH THIS CODE)
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uncomplicated delivery (O80)
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no documented indication. **MUST BE ACCOMPANIED BY A DELIVERY CODE** **USE ADDITIONAL CODE TO INDICATE OUTCOME OF DELIVERY**
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encounter for cesarean delivery (O82)
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any complication occurring within the six-week period
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postpartum complication
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last month of pregnancy to five months postpartum.
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puerperium period
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one of the most serious manifestations of major postpartum infection, complication occurs during the 6 weeks or 42 days following delivery **USE ADDITIONAL CODE TO IDENTIFY INFECTIOUS AGENT** B95-B97
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Puerperal Sepsis (O85)
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when a mother delivers outside of the hospital prior to admission and is admitted for routine postpartum care and no complications are noted, code?
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Z39.0
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identifies localized infections that occur during the postpartum period such as infection of obstetric surgical wound, other infection of genital tract, UTI, and other conditions
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Other puerperal infection (O86)
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during pregnancy, childbirth, or puerperal a patient admitted because of HIV related illness should receive principal diagnosis from ____ ? FOLLOWED BY CODE FOR _______________
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HIV (O98.7)
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patients with an asymptomatic HIV infection status admitted during pregnancy, childbirth, or the puerperium should receive codes of O98.7- and what code?
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Z21
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utilize these codes (subcategory O99.34-) to code other mental disorders classifiable to F01-F09 and F20-F99
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mental disorders (O99.3)
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other specified diseases and conditions complicating pregnancy, childbirth and the puerperium **USE ADDITIONAL CODE TO IDENTIFY THE CONDITION**
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other specified (O99.8)
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O99.82- carrying strep B, but doesn't have active infection.
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streptococcus B-carrier state
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Z30: encounter for contraceptive management Z31: encounter for procreative management Z32: encounter for pregnancy test and childbirth and childcare instruction Z33: pregnant state Z34: encounter for supervision of normal pregnancy Z36: encounter for antenatal screening of mother Z3A: weeks of gestation Z37: outcome of delivery Z39: encounter for maternal postpartum care and examination
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pregnancy related Z codes
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begins immediately after delivery and continues for six weeks following delivery.
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postpartum period
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when an attempted termination of pregnancy results in a liveborn fetus, assign a code from subcategory ____ and a code from ____
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O60.1 Z37.
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code for encounter for uncomplicated elective termination of pregnancy.
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Z33.2
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code used to describe the encounter for antenatal or prenatal screening of the pregnant female.
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Z36
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what codes are used to classify abortion complications that arise during an admission and encounter?
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O03 (spontaneous abortion)
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what codes are used to classify abortion complications that result following abortion completed during a previous admission?
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O04
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what codes are assigned for prenatal visits in high risk pregnancies?
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O09 (supervision of high risk pregnancies)
