19-1
Chapter 19 Coding for Obstetrics and Gynecology
THE COMPLETE DIAGNOSIS
CODING SOLUTION
THIRD EDITION
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19-2
Learning Outcomes
19.1 Identify the components of the
female genital system.
19.2 Explain the stages of reproduction.
19.3 Apply guidelines for coding routine
obstetrics.
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19-3
Learning Outcomes (cont.)
19.4 Determine the correct codes for
reporting complications of pregnancy.
19.5 Correctly report labor and delivery
encounters.
19.6 Enumerate the common gynecologic
diseases.
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19-4
Key Terms
• Abortion
• Breasts
• Cervix
• Clitoris
• Endometrium
• Fallopian tubes
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19-5
Key Terms (cont.)
• Gestation
• Gynecologist
• Labium majus
• Labium minus
• Mons pubis
• Obstetrics
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19-6
Key Terms (cont.)
• Ovaries
• Prenatal
• Puerperium
• Uterus
• Vagina
• Vulva
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19-7
Introduction
Females of all ages go to the gynecologist
(GYN) for specialized health care.
Sometimes, the physician is referred to as an
OB/GYN, an abbreviation for the dual
specialization of obstetrics (OB), which
focuses on care during pregnancy and
puerperium, and gynecology.
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19-8
The Female Genital System
The Breast
Across the top of the chest, laterally from the
midline where the sternum lies, are fleshy
mammary glands, commonly referred to as
the breast.
Learning Outcome: 19.1
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19-9
The Female Genital System
The Breast
• The main area of the breast is known as the
body.
• A secondary area, known as the axillary tail,
reaches toward the axilla (armpit).
• The nipple protrudes from the center of the
areola, the circle of pigmented (colored) skin.
Learning Outcome: 19.1
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19-10
Internal Female Genitalia
• Internally, a women’s reproductive
tract consists of the:
– Ovaries (oophors)
– Fallopian tubes (oviducts)
– Uterus
– Endometrium
– Cervix
– Vagina
Learning Outcome: 19.1
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19-11
External Female Genitalia
Collectively, the external genitalia of the
female are known as the vulva. It
comprises the mons pubis, the
clitoris, the labium minus (plural labia
minora), and the labium majus (plural
labia majora). The vaginal opening is in
the approximate center of this area.
Learning Outcome: 19.1
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19-12
Reproduction
Fertilization and Gestation
• When a sperm fertilizes an oocyte, a zygote is
created.
• Typically occurs while the egg is still in the last
portion of the fallopian tube.
• Embryonic period, from weeks 2 through 8 after
fertilization, is the time during which external
structures and internal organs begin to form.
Learning Outcome: 19.2
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19-13
Weeks of Gestation
Gestation, the length of the pregnancy, is
measured in trimesters, beginning on the
first day of the last menstrual period
(LMP).
Learning Outcome: 19.2
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19-14
Weeks of Gestation (cont.)
For coding purposes, ICD-10-CM provides the
following definitions:
– First trimester
– Second trimester
– Third trimester
– Preterm (premature) neonate
– Post-term neonate
– Prolonged gestation of a neonate
Learning Outcome: 19.2
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19-15
Routine Obstetric Care
Prenatal Visits
A woman often has three items noted in her chart:
gravida (G) reports how many times the woman has
been pregnant; para, or parity (P) reports how many
babies the woman has given birth to; and abortus (A)
identifies how many pregnancies did not come to term
or make it past the 20th week. Gravida and para may
be noted using an abbreviation, such as G2P1.
Learning Outcome: 19.3
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19-16
Normal Pregnancy
• Routine outpatient prenatal checkups
are very important to the health of the
mother and baby.
• When coding routine visits, if the patient
has no complications, choose from the
available Z codes.
Learning Outcome: 19.3
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19-17
High-Risk Pregnancy
In cases where the pregnancy is
considered to be medically high risk, you
will use a code from category O09,
Supervision of high-risk pregnancy, for the
routine visit.
Learning Outcome: 19.3
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19-18
Incidental Pregnant State
• When a pregnant woman comes in for
services or treatment from a physician for
a reason not concerning the pregnancy,
include code Z33.1, Pregnant state,
incidental, to indicate the pregnancy.
• It will never be the first-listed code.
Learning Outcome: 19.3
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19-19
Pregnancies with Complications
A complication of pregnancy is
considered to be any condition or
illness that may:
– Threaten the pregnant state.
– Affect or threaten the health of the woman.
– Influence the manner in which the woman will
be treated, such as preexisting cardiovascular
disease or chromosomal abnormality in the
fetus.
Learning Outcome: 19.4
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Preexisting Conditions Affecting
Pregnancy
Some diseases and illnesses are coded
differently when the only thing that has
changed is that the woman is now
pregnant.
Learning Outcome: 19.4
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19-20
19-21
Gestational Conditions
Gestational conditions develop as a result
of any of the many changes a woman’s
body goes through and are typically
transient.
Learning Outcome: 19.4
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19-22
Multiple Gestations
Code category O30 provides you with code
options available to report a multiple gestation.
Learning Outcome: 19.4
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19-23
Multiple Gestations (cont.)
In addition to determining the number of fetuses
from the documentation, you will also need to
determine:
– The number of placenta
– The number of amniotic sacs
– The specific trimester the gestation is in during this
encounter
Learning Outcome: 19.4
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19-24
Fetal Abnormalities
• When a woman is pregnant, all care for both
her and the baby is provided to the woman.
• Therefore, if there is a change in treatment or
care of the mother that is prompted by an
issue with the fetus, it must be documented
and reported.
Learning Outcome: 19.4
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19-25
Seventh Character
• Many of these codes require a seventh
character. If the pregnancy is a single
gestation, you will report a zero (0).
• When there is more than one fetus, you will
need to determine from the documentation
which specific fetus is having problems
described by the code.
Learning Outcome: 19.4
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19-26
Labor and Delivery
On the mother’s chart, every encounter that
results in the birth of a baby requires at least
two codes:
– The delivery itself
– The outcome of that delivery—number of
babies, alive or not (Z37.-)
Learning Outcome: 19.5
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19-27
Normal Delivery
For a spontaneous, full-term, vaginal,
live-born, single infant delivery with no
current complications or issues related to
the pregnancy, your principal diagnostic
code will be:
O80 Encounter for full-term uncomplicated
delivery
Learning Outcome: 19.5
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Special Circumstances Related
to Delivery
There may be an issue that requires
ongoing observation, admission into the
hospital, or some other factor requiring a
change to the original delivery plan.
O64.1xx- Obstructed labor due to breech
presentation
Learning Outcome: 19.5
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19-28
19-29
Outcome of Delivery
• Every time a patient gives birth during an
encounter, you have to code the birth
process and you have to report the
results of that birth process.
• The very last code on the mother's chart
that will have anything to do with the
baby is a code chosen from the Z37,
Outcome of delivery, category.
Learning Outcome: 19.5
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19-30
Postpartum and Peripartum
Conditions
• After the birth, the woman’s body
continues to change.
• The postpartum period begins at
delivery and extends for 6 weeks.
• The peripartum period runs the
beginning of the last month of
pregnancy and ends 5 months after
delivery.
Learning Outcome: 19.5
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19-31
Sequelae (Late Effects) of Obstetric
Complications
• Late effects of obstetric complications, as
identified by the physician’s notes, are
coded the same way as all other
sequelae.
• The late effect code O94, Sequelae of
complication of pregnancy, childbirth, and
the puerperium, is added when a
condition begins during pregnancy but
requires continued treatment.
Learning Outcome: 19.5
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19-32
Abortive Outcomes
• Abortions can be spontaneous (caused
by a biological or natural trigger) or
induced.
• A miscarriage is clinically known as an
abortion.
Learning Outcome: 19.5
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19-33
Routine Encounters
• Most women understand the
importance of getting their annual
well-woman examination.
• Often the visit includes a
Papanicolaou cervix smear, better
known as a Pap smear.
Learning Outcome: 19.5
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19-34
Procreative Management
• A woman may want to see her doctor
regarding her desire to have children now
or in the future.
• Code category Z31, Encounter for
procreative management, is used only for
testing conducted with anticipation of
procreation.
Learning Outcome: 19.5
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19-35
Other Gynecologic Conditions
Concerns and disorders relating to
other aspects of the female anatomy
are not related to pregnancy:
• Endometriosis
• Uterine fibroids
• Pelvic pain
Learning Outcome: 19.6
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19-36
Sexually Transmitted Diseases
• Bacterial vaginosis (BV)
• Chlamydia
• Genital herpes
• Gonorrhea
• Human immunodeficiency virus
Learning Outcome: 19.6
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19-37
Sexually Transmitted Diseases (cont.)
• Human papillomavirus
• Pelvic inflammatory disease
• Syphilis
• Trichomoniasis (trich)
Learning Outcome: 19.6
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19-38
Chapter Summary
• The anatomical sites included in the
female genital system are the definitions of
the phrase “private places.”
• These organs have important functions
and are susceptible to disease and injury.
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