Presented by: Andrea Romero
April 12, 2012
HFMA/NMHIMA Spring Conference
Objectives
 Compare and contrast ICD-9 and ICD-10 general rules
for obstetric cases from the coding guidelines for
obstetrical coding
 Provide specific examples of obstetrical coding in ICD10
 Compare and contrast ICD-9 and ICD-10 coding
guidelines for injury coding
 Provide specific examples of injury coding in ICD-10
General Rules for Obstetric Cases
ICD-9-CM
 Codes from chapter 11 and
sequencing priority
 Obstetric cases require codes from
chapter 11, codes in the range 630679, Complications of Pregnancy,
Childbirth, and the Puerperium.
Chapter 11 codes have sequencing
priority over codes from other
chapters. Additional codes from
other chapters may be used in
conjunction with chapter 11 codes
to further specify conditions.
Should the provider document
that the pregnancy is incidental to
the encounter, then code V22.2
should be used in place of any
chapter 11 codes. It is the
provider’s responsibility to state
that the condition being treated is
not affecting the pregnancy.
ICD-10-CM
 Codes from chapter 15 and
sequencing priority
 Obstetric cases require codes from
chapter 15, codes in the range
O00-O9A, Pregnancy, Childbirth,
and the Puerperium. Chapter 15
codes have sequencing priority
over codes from other chapters.
Additional codes from other
chapters may be used in
conjunction with chapter 15 codes
to further specify conditions.
Should the provider document
that the pregnancy is incidental to
the encounter, then code Z33.1,
Pregnant state, incidental, should
be used in place of any chapter 15
codes. It is the provider’s
responsibility to state that the
condition being treated is not
affecting the pregnancy.
General Rules for Obstetric Cases
ICD-9-CM
ICD-10-CM
 Chapter 11 codes used only
 Chapter 15 codes used only
on the maternal record
 Chapter 11 codes are to be
used only on the maternal
record, never on the record
of the newborn.
on the maternal record
 Chapter 15 codes are to be
used only on the maternal
record, never on the record
of the newborn.
General Rules for Obstetric Cases
ICD-9-CM
 Chapter 11 fifth-digits
 Categories 640-649, 651-676
have required fifth-digits,
which indicate whether
the encounter is
antepartum, postpartum
and whether a delivery has
also occurred.
ICD-10-CM
 Final character for trimester
 The majority of codes in Chapter
15 have a final character indicating
the trimester of pregnancy. The
timeframes for the trimesters are
indicated at the beginning of the
chapter. If trimester is not a
component of a code it is because
the condition always occurs in a
specific trimester, or the concept
of trimester of pregnancy is not
applicable. Certain codes have
characters for only certain
trimesters because the condition
does not occur in all trimesters,
but it may occur in more than just
one.
Timeframes for Trimesters
 Trimesters are counted from the first day of the last
menstrual period. They are defined as follows:
 1st trimester- less than 14 weeks 0 days
 2nd trimester- 14 weeks 0 days to less than 28 weeks 0
days
 3rd trimester- 28 weeks 0 days until delivery
General Rules for Obstetric Cases
ICD-9-CM
ICD-10-CM
 Fifth-digits, appropriate
 Assignment of the final
for each code
 The fifth-digits, which are
appropriate for each code
number, are listed in
brackets under each code.
The fifth-digits on each code
should all be consistent with
each other. That is, should a
delivery occur all of the fifthdigits should indicate the
delivery.
character for trimester should be
based on the provider’s
documentation of the trimester
(or number of weeks) for the
current admission/encounter.
This applies to the assignment of
trimester for pre-existing
conditions as well as those that
develop during or are due to the
pregnancy. The provider’s
documentation of the number
of weeks may be used to assign
the appropriate code identifying
the trimester.
General Rules for Obstetric Cases
ICD-9-CM
ICD-10-CM
 N/A
 Whenever delivery occurs
during the current admission,
and there is an “in childbirth”
option for the obstetric
complication being coded,
the “in childbirth” code
should be assigned.
General Rules for Obstetric Cases
ICD-9-CM
 N/A
ICD-10-CM
 Selection of trimester for inpatient
admissions that encompass more
than one trimesters
 In instances when a patient is admitted to
a hospital for complications of pregnancy
during one trimester and remains in the
hospital into a subsequent trimester, the
trimester character for the antepartum
complication code should be assigned on
the basis of the trimester when the
complication developed, not the trimester
of the discharge. If the condition
developed prior to the current
admission/encounter or represents a preexisting condition, the trimester character
for the trimester at the time of the
admission/encounter should be assigned.
General Rules for Obstetric Cases
ICD-9-CM
ICD-10-CM
 N/A
 Unspecified trimester
 Each category that includes
codes for trimester has a code for
“unspecified trimester.” The
“unspecified trimester” code
should rarely be used, such as
when the documentation in the
record is insufficient to
determine the trimester and it is
not possible to obtain
clarification.
General Rules for Obstetric Cases
ICD-9-CM
 N/A
ICD-10-CM
 7th character for Fetus Identification
 Where applicable, a 7th character is to be
assigned for certain categories (O31, O32,
O33.3 - O33.6, O35, O36, O40, O41,
O60.1, O60.2, O64, and O69) to identify
the fetus for which the complication code
applies.
 Assign 7th character “0”:
 For single gestations
 When the documentation in the record is
insufficient to determine the fetus
affected and it is not possible to obtain
clarification.
 When it is not possible to clinically
determine which fetus is affected.
ICD-10-PCS Guidelines:
Obstetrics section
 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.
ICD-10-PCS Guidelines:
Obstetrics 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.
Obstetric Section: Root Operations
 There are twelve root operations in the Obstetrics
section
 Two Root Operations unique to this section
 Abortion – artificially terminating a pregnancy
 Delivery – assisting the passage of the products of
conception from the genital canal
 Other Root Operations same as Medical and Surgical
Section
 Change, Drainage, Extraction, Insertion, Inspection,
Removal, Repair, Reposition, Resection, Transplantation
Obstetrical Case Study
 A 36-year-old G2 P1 woman is 39 weeks pregnant. She
has a dichorionic/diamniotic twin pregnancy with
Twin #1 in breech presentation. She also has
gestational hypertension.
She is admitted due to active labor. Twin #2 is
delivered vaginally over a midline episiotomy. Internal
version is successfully performed on Twin #1 and the
baby is also delivered vaginally. The episiotomy is
repaired.
Obstetrical Case Study
ICD-9-CM
ICD-10-CM
 652.11 Breech presentation,
 O32.1xx1 Breech presentation,




with successful version
651.01 Twin pregnancy,
delivered
642.31 Gestational
hypertension
V23.82 Elderly multigravida
V27.2 Outcome of delivery,
twins, liveborn




fetus #1
O30.043 dichorionic/
diamniotic twin pregnancy,
third trimester
O13.3 Gestational
hypertension, 3rd trimester
O09.523 Elderly multigravida,
3rd trimester
Z37.2 Outcome of delivery,
twins, liveborn
Obstetrical Case Study
ICD-9-CM Procedures
ICD-10-PCS
 73.59 Manually assisted
 10E0XZZ Delivery
delivery
 73.6 Episiotomy with
episiorrhaphy
 73.21 Version
 0W8NXZZ Episiotomy
 0WQNXZZ Episiorrhaphy
 10S07ZZ Version
Delivery
Because the
procedure is
being
performed on
products of
conception a
code from the
Obstetrics
section is used
Episiotomy
Because the
procedure is being
performed on the
mother a code
from the Medical
and Surgical
section is used
Episiorrhaphy
Because the procedure
is being performed on
the mother a code
from the Medical and
Surgical section is used
Version
Because the
procedure is
being
performed on
products of
conception a
code from the
Obstetrics
section is used
QUESTIONS?
Application of
ICD-9-CM
 N/A
th
7
Character
ICD-10-CM
 Most categories in chapter 19 have
a 7th character requirement for
each applicable code. Most
categories in this chapter have
three 7th character values (with
the exception of fractures): A,
initial encounter, D,
subsequent encounter and S,
sequela. Categories for
traumatic fractures have
additional 7th character values.
Application of
ICD-9-CM
 N/A
th
7
Character
ICD-10-CM
 7th character “A”, initial
encounter is used while the
patient is receiving active
treatment for the condition.
Examples of active treatment are:
surgical treatment, emergency
department encounter, and
evaluation and treatment by a
new physician.
Application of
ICD-9-CM
 N/A
th
7
Character
ICD-10-CM
 7th character “D” subsequent
encounter is used for encounters
after the patient has received active
treatment of the condition and is
receiving routine care for the
condition during the healing or
recovery phase. Examples of
subsequent care are: cast change or
removal, removal of external or
internal fixation device, medication
adjustment, other aftercare and
follow up visits following treatment
of the injury or condition.
Application of
th
7
Character
ICD-9-CM
ICD-10-CM
 N/A
 The aftercare Z codes should
not be used for aftercare for
conditions such as injuries
or poisonings, where 7th
characters are provided to
identify subsequent care.
For example, for aftercare
of an injury, assign the
acute injury code with the
7th character “D”
(subsequent encounter).
Application of
th
7
Character
ICD-9-CM
ICD-10-CM
 N/A
 7th character “S”, sequela, is for use for
complications or conditions that arise as a
direct result of a condition, such as scar
formation after a burn. The scars are
sequelae of the burn. When using 7th
character “S”, it is necessary to use both
the injury code that precipitated the
sequela and the code for the sequela
itself. The “S” is added only to the injury
code, not the sequela code. The 7th
character “S” identifies the injury
responsible for the sequela. The specific
type of sequela (e.g. scar) is sequenced
first, followed by the injury code.
Coding of Injuries
ICD-9-CM
ICD-10-CM
 When coding injuries, assign
 When coding injuries, assign
separate codes for each injury
unless a combination code is
provided, in which case the
combination code is assigned.
Multiple injury codes are provided
in ICD-9-CM, but should not be
assigned unless information for a
more specific code is not available.
These traumatic injury codes are
not to be used for normal, healing
surgical wounds or to identify
complications of surgical wounds.
 The code for the most serious
injury, as determined by the
provider and the focus of
treatment, is sequenced first.
separate codes for each injury
unless a combination code is
provided, in which case the
combination code is assigned.
Code T07, Unspecified multiple
injuries should not be assigned in
the inpatient setting unless
information for a more specific
code is not available. Traumatic
injury codes (S00-T14.9) are not to
be used for normal, healing
surgical wounds or to identify
complications of surgical wounds.
 The code for the most serious
injury, as determined by the
provider and the focus of
treatment, is sequenced first.
Injury Case Study
 A 19-year-old male suffered a fracture of C3 with
complete transection of the spinal cord at that level.
The injury occurred due to a tackle in a football game.
It happened on a football field. The patient is a student
who is on a recreational football team.
Injury Case Study
ICD-9-CM
ICD-10-CM
 806.01 Fracture of C3
 S12.200A Fracture C3
 S14.113A Transection of spinal




w/transection of spinal cord
E886.0 Tackle in sports
E007.0 Activities involving
American tackle football
E849.4 Occurring at place for
recreation and sport
E000.8 Sport, not for income,
while a student




cord
W03.xxxA Fall on same level
due to collision
Y93.61 Activities involving
American tackle football
Y92.321 Occurring at football
field
Y99.8 Sport, not for income,
while a student
Fracture C3
th
7
Character
Transection Spinal Cord
th
7
Character
Injury Case Study
 49-year-old male fell from a ladder inside a building
construction site and suffered an open skull fracture
with subarachnoid and subdural hemorrhage. He was
unconscious for 32 hours and expired without
regaining consciousness. He was an employed
construction worker.
Injury Case Study
ICD-9-CM
ICD-10-CM
 803.75 Open skull fracture
 S02.91xB Open skull fracture
 S06.6x7A Subarachnoid




with subarachnoid and
subdural hemorrhage,
prolonged LOC w/o return to
consciousness
E881.0 Fall from ladder
E016.2 Activities involving
construction
E849.3 Occurring at building
under construction
E000.0 Civilian activity for
pay





hemorrhage w/o return to
consciousness
S06.5x7A Subdural
hemorrhage w/o return to
consciousness
W11.xxxA Fall from ladder
Y93.H3 Activity, construction
Y92.61 Occurring at building
under construction
Y99.0 Civilian activity for pay
Skull Fracture
th
7
Character
Subarachnoid Hemorrhage
Subdural Hemorrhage
th
7
Character
QUESTIONS?