ICD-10-PCS: Obstetrics

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ICD-10-PCS: Obstetrics
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The ICD-10-PCS Official Guidelines for Coding and Reporting 2015 for Obstetrics are brief, only consisting of two points:
Products of conception
C1
Procedures performed on the products of conception are coded to the Obstetrics section. Procedures performed on the pregnant
female other than the products of conception are coded to the appropriate root operation in the Medical and Surgical section.
Example: Amniocentesis is coded to the products of conception body part in the Obstetrics section. Repair of obstetric urethral
laceration is coded to the urethra body part in the Medical and Surgical section.
Procedures following delivery or abortion
C2
Procedures performed following a delivery or abortion for curettage of the endometrium or evacuation of retained products of
conception are all coded in the Obstetrics section, to the root operation Extraction and the body part Products of Conception,
Retained. Diagnostic or therapeutic dilation and curettage performed during times other than the postpartum or post-abortion period
are all coded in the Medical and Surgical section, to the root operation Extraction and the body part Endometrium.
There is only one Body System (character 2): Pregnancy.
There are three Body Part characters (character 4):
1.
Products of conception;
2.
Products of conception, retained;
3.
Products of conception, eptopic.
There are currently only twelve Root Operations (character 3) in the Obstetrics Section, two of which only appear in
this section, Delivery and Abortion:
1.
Change
2.
Drainage
3.
Abortion - Artificially terminating a pregnancy
4.
Extraction
5.
Delivery - Assisting the passage of the products of conception from the genital canal (only used for manually assisted vaginal
deliveries)
6.
Insertion
7.
Inspection
8.
Removal
9.
Repair
10.
Reposition
11.
Resection
12.
Transplantation
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Scenario 1:
27 year old G2P1 at 39 weeks gestation presents in active labor. AROM is performed and spontaneous vaginal delivery over
intact perineum occurs 2 hours later.
What does the coder know?
Vaginal delivery 10E0XZZ
Intact perineum No Code
AROM to augment labor 10907ZC
•
•
•
ICD-10-PCS Index - Vaginal delivery
Delivery
Cesarean see Extraction, Products of Conception 10D0
Forceps see Extraction, Products of Conception 10D0
Manually assisted 10E0XZZ
ICD-10-PCS Table
10E
Section
1
Obstetrics
Body System
0
Pregnancy
Operation
E
Delivery: Assisting the passage of the products of conception from the genital canal
Body Part
Approach
0 Products of Conception
Device
X External
Qualifier
Z No Device
No Qualifier
ICD-10-PCS Index - AROM
AROM (artificial rupture of membranes) 10907ZC
ICD-10-PCS Table
109
Section
1
Obstetrics
Body System
0
Pregnancy
Operation
9
Drainage: Taking or letting out fluids and/or gases from a body part
Body Part
0 Products of Conception
Approach
Device
0 Open
3 Percutaneous
4 Percutaneous Endoscopic
Qualifier
9 Fetal Blood
A Fetal Cerebrospinal Fluid
Z No Device
B Fetal Fluid, Other
7 Via Natural or Artificial Opening
C Amniotic Fluid, Therapeutic
8 Via Natural or Artificial Opening Endoscopic
D Fluid, Other
U Amniotic Fluid, Diagnostic
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Scenario 2:
24 year old G1P0 at 37 weeks gestation presents in active labor. A vaginal, vacuum assisted, delivery occurs 8 hours later.
A second degree perineal laceration is repaired.
What does the coder know?
1.
A second degree perineal laceration is repaired 0KQM0ZZ
2.
A vacuum delivery 10D07Z6
What does the coder need to know?
First:
•
Sequencing of the procedures is based on both diagnostic and procedural Guidelines
When a delivery occurs, the principal diagnosis should correspond to the main circumstances or complication of the delivery.
•
•
Second:
2nd degree laceration is the main complication in this case
Sequence procedure performed for definitive treatment most related to principal diagnosis as principal procedure.
The anatomy involved in obstetrical lacerations.
•
1st degree - involves the skin and subcutaneous tissue of the perineum
•
2nd degree - involves the skin and subcutaneous tissue of the perineum, and pelvic floor muscles
•
3rd degree - involves the skin and subcutaneous tissue of the perineum, pelvic floor muscles, and the anal sphincter
•
4th degree - involves the skin and subcutaneous tissue of the perineum, pelvic floor muscles, the anal sphincter, and the rectal
mucosa
Third:
The Guideline dealing with “Overlapping body layers”
B3.5
If the root operations Excision, Repair or Inspection are performed on overlapping layers of the musculoskeletal system, the
body part specifying the deepest layer is coded.
ICD-10-PCS Index - A second degree perineal laceration is repaired
Repair
Muscle
Perineum 0KQM
ICD-10-PCS Table
0KQ
Section
0
Body System
K
Muscles
Operation
Q
Repair: Restoring, to the extent possible, a body part to its normal anatomic structure and function
Medical and Surgical
Body Part
Approach
D Hand Muscle, Left
0 Open
F Trunk Muscle, Right
3 Percutaneous
G Trunk Muscle, Left
4 Percutaneous Endoscopic
Device
Z No Device
Qualifier
Z No Qualifier
H Thorax Muscle, Right
J Thorax Muscle, Left
K Abdomen Muscle, Right
L Abdomen Muscle, Left
M Perineum Muscle
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ICD-10-PCS Index - A vacuum delivery
Delivery
Manually assisted 10E0XZZ
Products of Conception 10E0XZZ
Vacuum assisted see Extraction, Products of Conception 10D0
ICD-10-PCS Table
10D
Section
1
Obstetrics
Body System
0
Pregnancy
Operation
D
Extraction: Pulling or stripping out or off all or a portion of a body part by the use of force
Body Part
Approach
Device
Qualifier
3 Low Forceps
4 Mid Forceps
0 Products of Conception
7 Via Natural or Artificial Opening
Z No Device
5 High Forceps
6 Vacuum
7 Internal Version
8 Other
Scenario 3:
27 year old G3P1A1 at 38 weeks gestation presents in active labor. Maternal fatigue 10 hours later necessitates a low
forceps delivery over a midline episiotomy.
What does the coder know?
•
A low forceps delivery 10D07Z3
•
A midline episiotomy 0W8NXZZ
What does the coder need to know?
•
Referring back the first Guideline referenced: “Procedures performed on the pregnant female other than the products of
conception are coded to the appropriate root operation in the Medical and Surgical section.”
•
The episiotomy is performed on the pregnant female and must be coded in the Medical and Surgical section
ICD-10-PCS Index - A low forceps delivery
Delivery
Cesarean see Extraction, Products of Conception 10D0
Forceps see Extraction, Products of Conception 10D0
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ICD-10-PCS Table
10D
Section
1
Obstetrics
Body System
0
Pregnancy
Operation
D
Extraction: Pulling or stripping out or off all or a portion of a body part by the use of force
Body Part
Approach
Device
Qualifier
3 Low Forceps
0 Products of Conception
7 Via Natural or Artificial Opening
4 Mid Forceps
Z No Device
5 High Forceps
6 Vacuum
7 Internal Version
8 Other
ICD-10-PCS Index - A midline episiotomy
Episiotomy see Division, Perineum, Female 0W8N
ICD-10-PCS Table
0W8
Section
0
Medical and Surgical
Body System
W
Anatomical Regions, General
Operation
8
Division: Cutting into a body part, without draining fluids and/or gases from the body part, in order to separate or
transect a body part
Body Part
N Perineum, Female
Approach
X External
Device
Z No Device
Qualifier
Z No Qualifier
Note: The coder must be guided by documentation in the medical record of each individual case to make the correct code selections.
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