Transcript Chapter_007

CHAPTER 7
CHAPTER-SPECIFIC GUIDELINES
(ICD-10-CM CHAPTERS 15-21)
Pregnancy, Childbirth, and the
Puerperium, Chapter 15
 O00-O9A
 Any condition that occurs during pregnancy,
childbirth, or puerperium is a complication
– Unless physician documents it neither:
 Affects the pregnancy
 Is affected by the pregnancy
Sequencing Priority
 Chapter 15 codes have sequencing priority
of codes from other chapters
 Z33.1, incidental pregnancy state, is
reported if the physician documents
incidental status
 Chapter 15 codes are only for mother’s
record
– Never newborn’s record
Routine Prenatal Visits
 Routine outpatient prenatal visits with no
complications = Z34 category code
– First listed
 Routine high-risk prenatal visits = O09
category code
– First listed
Outcome of Delivery
 Outcome of delivery
– Z37 category code
– Only reported once
– On mother’s record
Trimester and Time Periods
 Majority of codes, final character indicates
trimester
 Trimester calculated from last menstrual period
(LMP)
– First trimester: less than 14 weeks 0 days
– Second trimester: 14 weeks 0 days to less than
28 weeks 0 days
– Third trimester: 28 weeks 0 days until delivery
 Peripartum = last month of pregnancy to 5
months postpartum
 Postpartum = immediately after delivery to 6
weeks after delivery
Ectopic Pregnancy
 Fertilized ovum implants outside the uterus
 Reported with category O00, based on:
– Location of pregnancy
 Such as: ovarian or tubal
 Complications associated with ectopic
pregnancy:
– Report category O08 code
Hydatidiform Mole
 Tumor of the placenta
– Secretes hormones
 Report with category O01
 Report complication with category O08
 Malignant, report D39.2
Hypertension in Pregnancy
 Pre-existing hypertension that complicates
the pregnancy, delivery, or the five-month
period after birth, Category O10
– First-listed code
Fetal Conditions
 Category O35 and O36 report fetal
abnormalities that affect the care of mother
 If fetal abnormality does not affect care of
mother, do not report O35 or O36
Diabetes Mellitus in Pregnancy
 Type 1 = little or no insulin is produced
– Controlled with insulin
– Report long-term use of insulin
 Type 2 = too little or the body cannot use the insulin that is
produced
– Controlled with diet, medications, and/or insulin
– May report long-term use of insulin
 Gestational diabetes develops in 2nd or 3rd trimester in
patient who did not have diabetes prior to pregnancy
– Do not report long-term use of insulin
Certain Conditions Originating
in the Perinatal Period,
Chapter 16
 P00-P96
 Chapter 16 codes only on newborn’s record
– Category Z38 reports liveborn according to place of
birth and type of delivery
– First listed
 Does not report congenital malformation,
deformities, or abnormalities
– Rather report with Q00-Q99
Congenital Malformations,
Deformation, and Chromosomal
Abnormalities, Chapter 17
 Q00-Q99
 May be a first-listed or secondary diagnosis
 Sequence as secondary diagnosis with
category Z38 code on initial birth record
 Reported whenever condition is diagnosed
 Congenital = born with
 Physician must document abnormality
Symptoms, Signs, and
Abnormal Clinical and
Laboratory Findings, NEC,
Chapter 18
R00-R99

 Sign = objective evidence of disease
 Symptom = subjective observation
 Report symptoms only when no more definitive
diagnosis is available
 Example: Pt complains of pain right lower
quadrant. Diagnosis states acute appendicitis.
– Do not report symptom of pain
Injury, Poisoning, and Certain
Other Consequences of
External Causes, Chapter 19
 S00-T88
 Many codes have 7th characters
 A initial encounter
– Receiving active treatment for the injury
 D subsequent encounter
– Completed active treatment and is receiving routine
care during healing
 S sequela
– Direct result of injury, add S to injury code, not to
sequela code
Traumatic Fractures
 Fractures not indicated as
– Open or closed, report as closed
– Displaced or not displaced, report as displaced
 Assign 7th character
–
–
–
–
–
–
A initial encounter for closed fracture
B initial encounter for open fracture
D subsequent encounter for fracture with routine healing
G subsequent encounter for fracture with delayed healing
K subsequent encounter for fracture with nonunion
S sequela
(Cont’d…)
Traumatic Fractures
(…Cont’d)
 Multiple fractures, sequence according to
severity
 If dislocation and fracture of same bone, report
only fracture
 Category M80 reports non-traumatic fracture for
patients with osteoporosis
– Even if injury by trauma
– Pathological fracture occurs due to disease or
weakness
Burns and Corrosions
 Thermal burns from heat source
– Except sunburn
 Corrosion burns due to chemicals
 Guidelines same for burns and corrosions
 Burns classified by depth:
– 1st erythema
– 2nd blistering
– 3rd full-thickness
(Cont’d…)
Burns and Corrosions
(…Cont’d)
 Sequence first
– Highest degree of burn
 Multiple burns, same area
– Report only the highest degree burn
 Infected burns
– Use additional code for infection
 Late effects of burns
– Report with burn or corrosion code + 7th character
“S”
Adverse Effects, Poisoning,
Underdosing, and Toxic Effects
 T36-T65
 Combination codes that include
– Substance
– External cause
 Sequence these codes 1st
– Follow with code(s) that specify nature
Poisoning
 Assign code from categories T36-T50,
poisoning codes
– Report any associated intent
 Such as, accidental, intentional, etc.
– Report all manifestations of poisoning
 Such as, vomiting
Drug Adverse Effect or Poisoning
 Adverse Effect: Occurs when drug is taken
correctly but patient has negative response
 Poisoning: Occurs when drug is incorrectly
taken
Abuse, Neglect, or Maltreatment
 Sequence first (T74.- or T76.-)
 Medical documentation states
– Abuse or neglect, code as confirmed
– Suspected, code as suspected
 Confirmed cases of abuse or neglect
– Report an assault code (X92-Y08) to indicate
cause of physical injury
– Report perpetrator code (Y07)
Conclusion
CHAPTER 7
CHAPTER-SPECIFIC GUIDELINES
(ICD-10-CM CHAPTER 15-21)
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