ICD-10 Coding SessionICD-10 Coding SessionOB/GYN/MidwiferyOB/GYN/Midwifery

Susan Fisher, CNM, MSN Director, Athens Regional Nurse-Midwifery Practice

Victoria A. Weinert, RHIT, CCS

Audit and Compliance Manager, On Assignment

Case 1Case 1Ms. Smith is a 40-year-old female, who presents for permanent sterilization. She has been seen by Dr. Jones and referred here. She has severe pulmonary fibrosis. This is the result of a severe MVA at age 13. She underwent pneumonectomy at that time and spent months at Egleston recovering. She has a splenectomy and lower lobe pneumonectomy. During this time she also had a pacemaker placed. She has no children and she understands that she should not have them with her medical conditions. She has tried other birth control methods and had various side effects which made continued use unfeasible. She desires permanent sterilization.

Case 1Case 1Past medical history: As above, severe MVA in 1986 with resultant pulmonary fibrosis. She also has migraine headaches.Past surgical history: As above, in addition cholecystectomy in 2008.Medications: Oxygen (24 hrs per day), Levaquin, LasixPhysical exam: Blood pressure 130/82, wt 201lbs, She has had a recent normal pap smear. Heart regular rate and rhythm. Lungs: Decreased breath sounds. The uterus is normal, cervix is nulliparous. Impression: Desire for permanent sterilizationSevere Pulmonary fibrosisObesityHypertension Plan: Will proceed with an Essure sterilization procedure under local anesthesia with sedation.

Essure SterilizationEssure Sterilization1. Placing the Essure inserts Your doctor will place a soft and flexible insert into each of your fallopian tubes. No incisions are needed because the inserts are placed through the natural pathway of your vagina and cervix. 2. Formation of the natural barrier Over the next 3 months, your body forms a natural barrier around the Essure inserts that prevent sperm from reaching your eggs. During the 3-month period, you must continue using another form of birth control. 3. Essure Confirmation Test After 3 months, a doctor administers the Essure Confirmation Test using contrast dye and a special type of x-ray. The test confirms that the inserts are placed correctly, your fallopian tubes are blocked, and pregnancy is permanently prevented. Until you receive confirmation from your doctor, you must continue to use another form of birth control to prevent pregnancy. http://www.essure.com/how-essure-works/the-essure-procedure

Coding Case 1Coding Case 1

What are the Diagnoses/Procedures?

Diagnoses Case 1Diagnoses Case 1

• Insertion Essure deviceProcedures Case 1Procedures Case 1

• Elective sterilization• Pulmonary Fibrosis• Obesity• Hypertension• History of Trauma to the Lung• Absence of Lung• Absence of spleen• Supplemental Oxygen

Case 2Case 2Ms. Jones is a 23-yr-old G3P2 at 36 wks and 5 days gestation who presents to the OB emergency department with leaking amniotic fluid and irregular contractions. She has a history of two previous preterm deliveries. In 2010 she had a normal spontaneous vaginal delivery of a stillborn male infant at 32 wks gestation. In 2012 she delivered a 3lb female infant at 34 wks gestation by cesarean section for severe IUGR. She has been followed closely this pregnancy, and the estimated fetal weight of this infant is appropriate for gestational age. She has gestational diabetes which is diet controlled.

Past Medical History: as above.Past Surgical History: Cesarean section with low transverse scar in 2012.

Case 2Case 2Impression:PPROM @ 36 wks 5 daysPremature DeliveryHistory of IUGR and stillbirth, currently pregnantGestational DiabetesObesity (BMI 36)Desires VBACGBS positive Plan: Patient was admitted for trial of labor. Outcome: Pt subsequently had a normal, unmedicated spontaneous vaginal delivery of a 5lb 6oz infant following 14 hours of labor. She had a first degree perineal laceration and an estimated blood loss of 300ml.

Coding Case 2Coding Case 2

What are the diagnoses/procedures?

Diagnoses Case 2Diagnoses Case 2

• Manually assisted vaginal deliveryProcedures Case 2Procedures Case 2

• PPROM/Premature Delivery• Previous C-section• Previous preterm deliveries• Previous stillbirth• Gestational diabetes, diet controlled• Obesity, BMI 36• GBS positive• Weeks of gestation• Outcome of Delivery

Case 3Case 3Ms. Garcia is a G2P0 with one previous miscarriage in the first trimester. Her first prenatal care visit was initiated at 26 wks and she had a total of five prenatal visits. The infant was found to have cleft lip/palate on a 26 wk anatomy scan. She presents to OB Emergency Dept today @ 39 wks gestation. She is 7 cm dilated with intact amniotic membranes. She requests epidural anesthesia. Her blood type is O- and she is GBS negative. Past medical/surgical history: 8 wk incomplete miscarriage with D&C in 2011.

Case 3Case 3Impression: G2P0 in active laborLate/Inadequate prenatal careFetus with cleft lip/palate Plan: Admit for labor, notify NICU to be present at delivery. Outcome: Seven hours after admission, Ms. Garcia had a vacuum assisted vaginal delivery of an 8lb 2oz infant. The infant was vigorous at birth and was attended to by the NICU team. Ms. Garcia had a fourth degree perineal laceration which was repaired by the attending MD. She had a postpartum hemorrhage with estimated blood loss of 600ml. The bleeding responded to pitocin and cytotec and her vital signs remained stable.

ICD-10-PCS Official Guidelines for ICD-10-PCS Official Guidelines for Coding and Reporting Coding and Reporting

B. Medical and Surgical Section Guidelines (section 0)B3. Root OperationOverlapping body layers B3.5 If the root operations Excision, Repair or Inspection are performed on overlapping layers of the musculoskeletal system, the body part specifying the deepest layer is coded. Example: Excisional debridement that includes skin and subcutaneous tissue and muscle is coded to the muscle body part.

Obstetrical Perineal LacerationsObstetrical Perineal LacerationsType Description Body Part Repaired

1st Degree Damage to the fourchette and vaginal mucosa, underlying muscles are exposed but not torn

• Skin, Perineum

2nd Degree Posterior vaginal walls and perineal muscles, but the anal sphincter is intact

• Subcu Tissue and Fascia, Perineum• Muscle, Perineum

3rd Degree Extends to the anal sphincter, but the rectal mucosa is intact

• GI, Anal sphincter

4th Degree Involve the rectal and anal mucosa GI, Rectum

Not specified

“Perineum”“Extended Episiotomy”

Anatomical Regions, General, Perineum

Taken from ICD-10- CM and ICD-10-PCS Coding Handbook 2014, p. 336

Coding Case 3Coding Case 3

What are the diagnoses/

procedures?

Diagnoses Case 3Diagnoses Case 3

• Vacuum Assisted Vaginal Delivery• Repair 4th degree perineal laceration• Infusion, pitocin/cytotec

Procedures Case 3Procedures Case 3

• Previous miscarriage• Inadequate prenatal care• Fetal Anomaly-cleft lip/palate• Fourth degree perineal laceration• Postpartum hemorrhage• Weeks of gestation• Outcome of delivery

Case 4Case 4A 46 yr old woman presented to the ER for menorrhagia, which required a transfusion of 4 units of blood. Her medical history is significant for morbid obesity (BMI 76) and cardiomyopathy. Past Medical History: As above. No current medications.Past Surgical History: NoneImpression:1) Menorrhagia2) Morbid Obesity3) CardiomyopathyPlan: Pt needs a D&C, consult Cardiology for clearance.Outcome: The patient was cleared for a D&C. However, an endometrial biopsy was scheduled first and was performed in our office today. The pathology report came back and showed well differentiated/FIGO Grade 1 endometrioid type adenocarcinoma with associated complex hyperplasia with atypia, and extensive morular metaplasia.

Coding Case 4Coding Case 4

What are the diagnoses/procedures?

Diagnoses Case 4Diagnoses Case 4

• Endometrial Biopsy

Procedures Case 4Procedures Case 4

• Endometrial Adenocarcinoma• Menorrhagia• Morbid Obesity, BMI 76• Cardiomyopathy

Case 5Case 5A 31 yr old G1P0 was admitted to Labor and Delivery for induction at 37/1 wks for mild preeclampsia. She has a twin gestation with dichorionic, diamniotic twins. Twin A is in vertex position and twin B is breech. She was also recently diagnosed with intrahepatic cholestasis of pregnancy. She has mild anemia. She desires a trial of labor and understands that internal version of twin B may be necessary or that cesarean section may be necessary. Past Medical History: UnremarkablePast Surgical History: None

Plan: Induction of labor.

Case 5Case 5Impression:IUP at 37/1 wksTwin Gestation Vertex/BreechPreeclampsiaIntrahepatic Cholestasis of PregnancyAnemia

Outcome: On admission, Cervidil vaginal suppository was placed followed by intravenous Pitocin. After 14 hours of labor, twin A was delivered spontaneously without complications. Twin B was internally verted and delivered one hour later without complications. Pt had a seizure immediately following the birth of twin B. She was given Ativan and started on intravenous magnesium sulfate. She had a postpartum hemorrhage.

QueryQueryPlease assist with clarification of the diagnosis of anemia. On admission hgb was _, hct was _. Delivery was complicated by postpartum hemorrhage. After delivery, hgb was _, hct was _. Can you further specify the type of anemia treated during this admission?_X_Hemorrhagic Anemia__Acute Posthemorrhagic Anemia__Other (please specify)

“The mild anemia was present antenatally and then worsened with the postpartum hemorrhage without need for transfusions.”

Coding Case 5Coding Case 5What are the diagnoses/procedures?

Diagnoses Case 5Diagnoses Case 5

• Manually assisted vaginal delivery• Medical induction of labor• Version of Twin B• Infusion magnesium sulfate

Procedures Case 5Procedures Case 5

• Mild pre-eclampsia• Postpartum hemorrhage• Twin gestation, di/di• Breech, fetus 2• Anemia• Intrahepatic cholestasis of pregnancy• Weeks of gestation• Outcome of delivery

How would you code the baby’s How would you code the baby’s records?records?

• Birth• Vaccinations?• Hearing Test?• Circumcision?