The Complete
Diagnosis Coding Book
by
Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA
Chapter 9
Coding Obstetrics
and Gynecology
McGraw Hill/Irwin
Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved
9-2
Learning Outcomes
· Apply guidelines for coding all aspects
of pregnancy.
· Determine the correct codes for
reporting complications of pregnancy.
· Correctly report labor and delivery
encounters.
9-3
Learning Outcomes
· Distinguish between antepartum and
postpartum conditions.
· Report the late effects of obstetric
complications accurately.
· Explain the different types of abortive
occurrences.
9-4
Introduction
· Females of all ages may go to a
gynecologist for specialized health care.
· Women who are pregnant are cared for
by an obstetrician.
9-5
Pregnancies
· Prenatal visits occur during
pregnancy and are scheduled
throughout the gestational period.
· These visits are predetermined, so
they are code with V codes.
9-6
Pregnancy
Complications: Conditions and
illnesses that
· threaten the pregnancy,
· threaten the health of the woman, or
· influence the treatment of the pregnancy.
9-7
Pregnancy
Fifth Digits: Complication codes:
· 1 Delivered, with or without mention of
an antepartum condition
· The woman gave birth to the baby at this
encounter and she may or may not have a
condition that complicated the pregnancy.
9-8
Pregnancy
· Fifth Digits: Complication codes:
· 2 Delivered, with mention of an
postpartum condition
· The woman gave birth to the baby at this
encounter and there is documentation of a
problem that occurred afterward.
9-9
Pregnancy
Fifth Digits: Complication codes:
· 3 Antepartum condition, not delivered
· The woman is still pregnant (she did NOT
give birth at this encounter) and there is
documentation of a complication.
9 - 10
Pregnancy
Fifth Digits: Complication codes:
· 4 Postpartum condition
· The woman gave birth to the baby
before this encounter and there is
documentation of a problem that
occurred after the birth.
9 - 11
Preexisting Conditions
· Preexisting illnesses are coded
differently when they complicate a
woman’s pregnancy.
· These are most often systemic
conditions.
9 - 12
Gestational Conditions
· Conditions and illnesses that develop in a
pregnant woman that are expected to
resolve (go away) once the baby is born
· Examples: Gestational hypertension
and Gestational diabetes
9 - 13
Fetal Conditions
· Any conditions identified in the fetus that
affect the treatment of the mother during
her pregnant state
· Example: Poor fetal growth may result in
the mother being referred to a nutritionist.
9 - 14
Labor and Delivery
The encounter when the baby is born is
reported with two codes:
· The actual delivery (the birth)
· Outcome of delivery (the baby)
9 - 15
Normal Delivery
· A spontaneous, full-term, vaginal,
live-born, single infant
· No complications
· Use code 650 Normal delivery
· With V27.0 Single live-born
9 - 16
Delivery
Anything else during delivery must be coded:
·
Multiple gestation
· Malposition of fetus
· Complications of delivery
· Cesarean delivery
9 - 17
Outcome of Delivery
· How many babies were born?
· Single, Twins, Triplets, and so on
· Live or stillborn
· Report with an Outcome of Delivery code:
V27.x
9 - 18
Postpartum Conditions
Routine Postpartum Conditions, just
like routine prenatal or other types of
care, are coded with V codes:
· V24.x Postpartum care and exam
· V24.0 Immediately after delivery
· V24.1 Lactating mother
· V24.2 Routine postpartum follow-up
9 - 19
Late Effects
When a physician specifically identifies a
condition with the mother as a
· Late effect of obstetric complications,
report with
· 677 Late effect of complication of pregnancy,
childbirth, and the puerperium.
9 - 20
Abortions
An abortion may be
· spontaneous: caused by biological or
natural triggers, or
· induced: caused by artificial or therapeutic
sources.
9 - 21
Abortions
Abortive events may be
· unspecified,
· incomplete, or
· complete.
9 - 22
Routine Gynecology
Routine Gynecological Care is coded
with V codes:
· V72.31 Routine gynecological exam
· V76.47 Special screening, vaginal
· V76.2 Special screening, cervix
· V25.x Contraceptive management
9 - 23
Other Testing
· V26.xx Procreative management
· V26.3x Genetic counseling and tests
· V72.4x Pregnancy exam or test
· V26.21 Fertility testing
9 - 24
Other Gynecology
· Endometriosis 617.0–617.9
· Uterine fibroids 218.0–218.9
· Pelvic pain 625.0–625.9
· Sexually transmitted diseases
·
·
·
·
·
Human papillomaviruses 079.4
Gonorrhea 098.0–098.89
Genital wart 078.19
Chlamydial infection 078.0–079.99
AIDS 042
9 - 25
Chapter Summary
· Female anatomy includes many organs
and anatomical sites that can be subject
to health concerns.
· During pregnancy, the health concerns
are even greater and require more
professional oversight.