CHAPTER 7CHAPTER 7CHAPTER-SPECIFIC GUIDELINES CHAPTER-SPECIFIC GUIDELINES
(ICD-10-CM CHAPTERS 15-21)(ICD-10-CM CHAPTERS 15-21)
Pregnancy, Childbirth, and the Pregnancy, Childbirth, and the Puerperium, Chapter 15Puerperium, Chapter 15
O00-O9AO00-O9A Any condition that occurs during pregnancy, Any condition that occurs during pregnancy,
childbirth, or puerperium is a complicationchildbirth, or puerperium is a complication– Unless physician documents it neither:Unless physician documents it neither:
Affects the pregnancyAffects the pregnancy Is affected by the pregnancyIs affected by the pregnancy
Sequencing PrioritySequencing Priority
Chapter 15 codes have sequencing priority Chapter 15 codes have sequencing priority of codes from other chaptersof codes from other chapters
Z33.1, incidental pregnancy state, is Z33.1, incidental pregnancy state, is reported if the physician documents reported if the physician documents incidental statusincidental status
Chapter 15 codes are only for mother’s Chapter 15 codes are only for mother’s recordrecord– Never newborn’s recordNever newborn’s record
Routine Prenatal VisitsRoutine Prenatal Visits
Routine outpatient prenatal visits with no Routine outpatient prenatal visits with no complications = Z34 category codecomplications = Z34 category code– First listedFirst listed
Routine high-risk prenatal visits = O09 Routine high-risk prenatal visits = O09 category codecategory code– First listed First listed
Outcome of DeliveryOutcome of Delivery
Outcome of deliveryOutcome of delivery– Z37 category codeZ37 category code– Only reported onceOnly reported once– On mother’s recordOn mother’s record
Trimester and Time PeriodsTrimester and Time Periods Majority of codes, final character indicates Majority of codes, final character indicates
trimestertrimester Trimester calculated from last menstrual period Trimester calculated from last menstrual period
(LMP)(LMP)– First trimester: less than 14 weeks 0 days First trimester: less than 14 weeks 0 days – Second trimester: 14 weeks 0 days to less than Second trimester: 14 weeks 0 days to less than
28 weeks 0 days 28 weeks 0 days – Third trimester: 28 weeks 0 days until deliveryThird trimester: 28 weeks 0 days until delivery
Peripartum = last month of pregnancy to 5 Peripartum = last month of pregnancy to 5 months postpartummonths postpartum
Postpartum = immediately after delivery to 6 Postpartum = immediately after delivery to 6 weeks after deliveryweeks after delivery
Ectopic PregnancyEctopic Pregnancy
Fertilized ovum implants outside the uterusFertilized ovum implants outside the uterus Reported with category O00, based on:Reported with category O00, based on:
– Location of pregnancyLocation of pregnancy Such as: ovarian or tubalSuch as: ovarian or tubal
Complications associated with ectopic Complications associated with ectopic pregnancy:pregnancy:– Report category O08 codeReport category O08 code
Hydatidiform MoleHydatidiform Mole
Tumor of the placentaTumor of the placenta– Secretes hormonesSecretes hormones
Report with category O01Report with category O01 Report complication with category O08Report complication with category O08 Malignant, report D39.2Malignant, report D39.2
Hypertension in PregnancyHypertension in Pregnancy
Pre-existing hypertension that complicates Pre-existing hypertension that complicates the pregnancy, delivery, or the five-month the pregnancy, delivery, or the five-month period after birth, Category O10period after birth, Category O10– First-listed codeFirst-listed code
Fetal ConditionsFetal Conditions
Category O35 and O36 report fetal Category O35 and O36 report fetal abnormalities that affect the care of motherabnormalities that affect the care of mother
If fetal abnormality does not affect care of If fetal abnormality does not affect care of mother, do not report O35 or O36mother, do not report O35 or O36
Diabetes Mellitus in Pregnancy Diabetes Mellitus in Pregnancy
Type 1 = little or no insulin is producedType 1 = little or no insulin is produced– Controlled with insulinControlled with insulin– Report long-term use of insulinReport long-term use of insulin
Type 2 = too little or the body cannot use the insulin that is Type 2 = too little or the body cannot use the insulin that is producedproduced– Controlled with diet, medications, and/or insulinControlled with diet, medications, and/or insulin– May report long-term use of insulinMay report long-term use of insulin
Gestational diabetes develops in 2nd or 3rd trimester in Gestational diabetes develops in 2nd or 3rd trimester in patient who did not have diabetes prior to pregnancypatient who did not have diabetes prior to pregnancy– Do not report long-term use of insulinDo not report long-term use of insulin
Certain Conditions Originating Certain Conditions Originating in the Perinatal Period, in the Perinatal Period,
Chapter 16Chapter 16 P00-P96P00-P96 Chapter 16 codes only on newborn’s recordChapter 16 codes only on newborn’s record
– Category Z38 reports liveborn according to place of Category Z38 reports liveborn according to place of birth and type of deliverybirth and type of delivery
– First listedFirst listed
Does not report congenital malformation, Does not report congenital malformation, deformities, or abnormalitiesdeformities, or abnormalities– Rather report with Q00-Q99Rather report with Q00-Q99
Congenital Malformations, Congenital Malformations, Deformation, and Chromosomal Deformation, and Chromosomal
Abnormalities, Chapter 17Abnormalities, Chapter 17 Q00-Q99Q00-Q99 May be a first-listed or secondary diagnosisMay be a first-listed or secondary diagnosis Sequence as secondary diagnosis with Sequence as secondary diagnosis with
category Z38 code on initial birth recordcategory Z38 code on initial birth record Reported whenever condition is diagnosedReported whenever condition is diagnosed Congenital = born withCongenital = born with Physician must document abnormalityPhysician must document abnormality
Symptoms, Signs, and Symptoms, Signs, and Abnormal Clinical and Abnormal Clinical and
Laboratory Findings, NEC, Laboratory Findings, NEC, Chapter 18Chapter 18 R00-R99R00-R99
Sign = objective evidence of disease Sign = objective evidence of disease Symptom = subjective observationSymptom = subjective observation Report symptoms only when no more definitive Report symptoms only when no more definitive
diagnosis is availablediagnosis is available Example: Pt complains of pain right lower Example: Pt complains of pain right lower
quadrant. Diagnosis states acute appendicitis.quadrant. Diagnosis states acute appendicitis.– Do not report symptom of painDo not report symptom of pain
Injury, Poisoning, and Certain Injury, Poisoning, and Certain Other Consequences of Other Consequences of
External Causes, Chapter 19External Causes, Chapter 19 S00-T88S00-T88 Many codes have 7th charactersMany codes have 7th characters A initial encounterA initial encounter
– Receiving active treatment for the injuryReceiving active treatment for the injury D subsequent encounterD subsequent encounter
– Completed active treatment and is receiving routine Completed active treatment and is receiving routine care during healingcare during healing
S sequelaS sequela– Direct result of injury, add S to injury code, not to Direct result of injury, add S to injury code, not to
sequela codesequela code
Traumatic FracturesTraumatic Fractures Fractures not indicated as Fractures not indicated as
– Open or closed, report as closedOpen or closed, report as closed– Displaced or not displaced, report as displacedDisplaced or not displaced, report as displaced
Assign 7th character Assign 7th character – A initial encounter for closed fracture A initial encounter for closed fracture – B initial encounter for open fracture B initial encounter for open fracture – D subsequent encounter for fracture with routine healing D subsequent encounter for fracture with routine healing – G subsequent encounter for fracture with delayed healing G subsequent encounter for fracture with delayed healing – K subsequent encounter for fracture with nonunion K subsequent encounter for fracture with nonunion – S sequelaS sequela
(Cont’d…)
Traumatic FracturesTraumatic Fractures(…Cont’d)(…Cont’d)
Multiple fractures, sequence according to Multiple fractures, sequence according to severityseverity
If dislocation and fracture of same bone, report If dislocation and fracture of same bone, report only fractureonly fracture
Category M80 reports non-traumatic fracture for Category M80 reports non-traumatic fracture for patients with osteoporosispatients with osteoporosis– Even if injury by traumaEven if injury by trauma– Pathological fracture occurs due to disease or Pathological fracture occurs due to disease or
weaknessweakness
Burns and CorrosionsBurns and Corrosions
Thermal burns from heat sourceThermal burns from heat source– Except sunburnExcept sunburn
Corrosion burns due to chemicalsCorrosion burns due to chemicals Guidelines same for burns and corrosionsGuidelines same for burns and corrosions Burns classified by depth:Burns classified by depth:
– 1st erythema1st erythema– 2nd blistering2nd blistering– 3rd full-thickness3rd full-thickness
(Cont’d…)
Burns and CorrosionsBurns and Corrosions(…Cont’d)(…Cont’d)
Sequence firstSequence first– Highest degree of burnHighest degree of burn
Multiple burns, same areaMultiple burns, same area– Report only the highest degree burnReport only the highest degree burn
Infected burnsInfected burns– Use additional code for infectionUse additional code for infection
Late effects of burnsLate effects of burns– Report with burn or corrosion code + 7th character Report with burn or corrosion code + 7th character
“S”“S”
Adverse Effects, Poisoning, Adverse Effects, Poisoning, Underdosing, and Toxic EffectsUnderdosing, and Toxic Effects
T36-T65T36-T65 Combination codes that include Combination codes that include
– Substance Substance – External causeExternal cause
Sequence these codes 1stSequence these codes 1st– Follow with code(s) that specify natureFollow with code(s) that specify nature
PoisoningPoisoning
Assign code from categories T36-T50, Assign code from categories T36-T50, poisoning codespoisoning codes– Report any associated intentReport any associated intent
Such as, accidental, intentional, etc.Such as, accidental, intentional, etc.
– Report all manifestations of poisoningReport all manifestations of poisoning Such as, vomitingSuch as, vomiting
Drug Adverse Effect or PoisoningDrug Adverse Effect or Poisoning
Adverse Effect: Occurs when drug is taken Adverse Effect: Occurs when drug is taken correctly but patient has negative responsecorrectly but patient has negative response
Poisoning: Occurs when drug is incorrectly Poisoning: Occurs when drug is incorrectly takentaken
Abuse, Neglect, or MaltreatmentAbuse, Neglect, or Maltreatment
Sequence first (T74.- or T76.-)Sequence first (T74.- or T76.-) Medical documentation statesMedical documentation states
– Abuse or neglect, code as confirmedAbuse or neglect, code as confirmed– Suspected, code as suspectedSuspected, code as suspected
Confirmed cases of abuse or neglectConfirmed cases of abuse or neglect– Report an assault code (X92-Y08) to indicate Report an assault code (X92-Y08) to indicate
cause of physical injurycause of physical injury– Report perpetrator code (Y07)Report perpetrator code (Y07)
ConclusionConclusionCHAPTER 7CHAPTER 7
CHAPTER-SPECIFIC GUIDELINES CHAPTER-SPECIFIC GUIDELINES (ICD-10-CM CHAPTER 15-21) (ICD-10-CM CHAPTER 15-21)
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