Pregnancy, Childbirth and the Puerperium

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Pregnancy, Childbirth and the Puerperium

• HS317b Coding Classification of Health Data

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O00 O99 codes

• Classify pregnancy with abortive outcome,
  disorders predominantly related to pregnancy,
  maternal care, complications of labour and
  delivery and conditions related to the puerperium
• 6th digit of the diagnostic code will indicate
  the episode of care antepartum, delivery,
  postpartum

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Stages of Pregnancy

• Pregnancy with abortive outcomes
• Complications
• Pregnancy Antepartum
• Complications
• Pregnancy Delivery
• Complications
• Pregnancy -- Postpartum

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Episode of care 6th digit

• 1 Delivered, with or without mention of
  antepartum condition
• 2 Delivered, with mention of postpartum
  complication
• 3 Antepartum condition or complication
• 4 Postpartum condition or complication
• 9 Unspecified as to episode of care

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Gestational Age

• Completed weeks after the onset of the last
  normal menstrual period to delivery
• Preterm
• Less than 37 completed weeks
• i.e. O60.001 Preterm delivery, delivered, with or
  without mention of antepartum condition

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• Term
• 37 completed weeks to less than 41 completed
  weeks
• PostTerm
• Traditionally at 42 completed weeks but may be
  assigned at 41 weeks if designated by a physician
• O48.001 Prolonged pregnancy, delivered, with or
  without mention of antepartum condition

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Trimesters

• First trimester lt 13th week
• Second trimester 14th weekup to an including
  26th week
• Third trimester gt 26 week gestation

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Stages of Labour Delivery

• First stage
• Begins at onset of labour
• Ends at full dilation of cervix (10 cm)
• Second stage
• Begins at full dilation of cervix
• Ends at birth of the baby
• Third stage
• Begins at birth of baby
• Ends at delivery of placenta

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Obstetrical Experience

• Antepartum
• Begins at conception
• Ends at complete dilation of cervix
• Intrapartum
• Begins at complete dilation of cervix
• Ends at Birth of infant
• Postpartum
• Begins at birth of infant
• Ends as 42 days after birth of infant

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Pregnancy with abortive outcome

• Includes codes in the range of O03 O08
• Fourth digit of code
• Indicates associated complications
• Spontaneous abortion, incomplete, without
  complications O03.4

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Pregnancy with abortive outcome

• Types
• Medical
• Ectopic Molar
• Missed
• Spontaneous
• Failed Attempt

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Ectopic/Molar Pregnancy

• Ectopic pregnancy where fetus develops outside
  the uterusin fallopian tubes, cervical canal,
  abdominal or pelvic cavity
• Molar a tumorous growth of tissue from the
  placenta or afterbirth
• Excludes malignant hydatidiform mole (D39.2)

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Missed or Spontaneous Abortion

• Missed abortion
• Early fetal death before completion of 20 weeks
  gestation with retention of dead fetus
• Excludes mole hydatidiform (O01.-) and
  nonhydatidiform (O02.0)
• Spontaneous abortion
• Miscarriage (premature expulsion of fetus that
  occurs naturally and without cause)

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Medical, Other, Failed Abortions

• Medical abortion O04-O07
• Elective therapeutic
• Other abortion
• Self-inflicted, occurring after trauma
• Failed attempted abortion
• When termination does not result in terminating
  the pregnancy

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Complications following abortion

• ICD-10-CA makes a distinction between an episode
  of care at which the abortion/ectopic/molar
  pregnancy and any resulting complications are
  treated together and an episode of care for a
  complication of the abortion/ectopic/molar
  pregnancy treated previously

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• Ruptured tubal pregnancy with shock (initial
  episode of care)
• O00.1 (M) Tubal pregnancy
• O08.3 (2) Shock following abortion/ectopic/molar
  pregnancy

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• Incomplete spontaneous abortion with perforation
  of uterus (initial episode of care)
• O03.3(M) Spontaneous abortion, incomplete, with
  other and unspecified complications
• O08.6 (2) Damage to pelvic organs and tissues
  following abortion/ectopic/molar pregnancy

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• Mrs. S. had a spontaneous abortion and underwent
  a D C in the first episode of care. She was
  brought to ER two days after discharge because
  she developed a fever and was diagnosed with
  endometritis.
• O08.0(M) Genital tract and pelvic infection
  following abortion and ectopic and molar
  pregnancy

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Abortion Sixth digit 9

• Sixth digit 9
• Can be used for additional OBS conditions with
  abortive outcome.
• Therapeutic abortion because of fetal anomalies
  (Trisomy 21)
• O04.9 (M) Medical Abortion
• O35.009 (1) Maternal care for chromosomal
  abnormalities in fetus.

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Delivery in a completely normal case

• Normal delivery can include
• Spontaneous vertex delivery
• Single term liveborn
• Healthy mother delivered
• Occiput posterior and occiput transverse not
  stated as persistent
• No fetal manipulation or instrumentation

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Delivery in a completely normal case

• (M) Z37.0 Outcome of delivery, single live birth
• 5.MD.50. Manually assisted vaginal delivery
  (vertex)

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Outcome of delivery Z37.

• Mandatory to code for every delivery
• When other codes from Chapter XV apply to the
  case
• Z37. is classified as a diagnosis type 3.
• There must be a corresponding intervention code
  for delivery selected as your principal procedure

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• Certain obstetrical procedure do not
  contraindicate the use of Z37.0 as MRDx
• Induction for convenience
• Artificial rupture of membranes
• Simple manual removal of placenta
• Episiotomy
• Requested Cesarean Section in the absence of any
  indication

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Delivery

• Mandatory intervention needed between the range
  of 5.MD.50. to 5.MD.60. for every delivery.
  Code as principal procedure
• 5.MD.50. manually assisted vaginal delivery
• 5.MD.53. Forceps traction rotation
• 5.MD.54. Vacuum traction
• 5.MD.55. Combo vacuum forceps
• 5.MD.56. Breech delivery
• 5.MD.60. Caesarean Section

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Folio lookup

• Pregnancy
• amnionitis O41.19
• anemia (conditions in D50 D64) O99.0
• atrophy (acute) (subacute) (yellow),
  liver O26.6
• bicornis or bicornuate uterus O34.0
• bone and joint disorders of back, pelvis
  and lower limbs O99.8

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• Pregnancy
• -conditions in
• B50 B64, O98.6
• D50 D64, O99.0
• D65 D89, O99.1
• E40 E46, O25
• F00 F99, O99.3

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Delivery

• 1 indicates episode in which mother has
  delivered with or without mention of antepartum
  condition
• Antepartum condition with delivery
• Intrapartum obstetric condition
• Delivery NOS
• Pregnancy, delivered

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Sixth Digit Combinations

• 1 Delivery can be coded with
• 2 Delivered with complication
• 3 Antepartum condition can never be coded with
  1, 2, 4, or 9
• 4 Postpartum can never be used with 1, 2,
  3, or 9
• 9 should never be used for inpatient care except
  when the outcome is abortive

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Induction and Augmentation of Labour

• 5.AC.30. Induction of labour
• Assign when a patient presents for delivery with
  no physical signs of labour, and one of these
  interventions is performed to initiate labour
• Mandatory to code

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• 5.LD.31. Augmentation of labour
• Assign when labor begins spontaneously
• Optional to code
• Augmentation and induction should not be coded on
  the same chart
• Facility directed as to code augmentation
  induction in same episode

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Sequencing Obstetrical Dx

• If episode of care includes non-instrumental,
  vaginal delivery of an infant but the mother was
  admitted for an antepartum condition that
  required treatment for more than five days before
  the birth, sequence the antepartum condition as
  MRDx

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• In cases within the expected LOS (3 to 5 days)
  where Caesarean section or instrumentation
  (forceps or vacuum) has been used, a diagnosis
  stating the indication for the intervention
  should be the MRDx

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Exclusion/Inclusion notes

• O32.1 Maternal care for breech presentation
• Excludes the listed conditions with obstructed
  labour (O64.-)
• O64.1 Obstructed labour due to breech
  presentation

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Codes O32-O34 vs O64-O66

• Use these codes when mother is diagnosed with
  these conditions prior to the onset of labour.
• When labour has begun, medical intervention is
  required due to one of the conditions, the case
  should be classified from the range of O64-O66
  Obstructed Labour

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Newborn

• Code Z38.0 for every newborn
• Z38.00 Singleton, born in hospital, delivered
  vaginally
• Z38.01 Singleton, born in hospital, delivered by
  caesarean
• Z38.1 Singleton, born outside hospital
• Z38.2 Singleton, unspecified as to place of birth

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Diagnosis type 0

• If there is another contra-indication, Z38.0
  must still be coded but as a diagnosis type 0
• No diagnosis type 3 is allowed for newborn coding
• Capture Z38 to distinguish babies born via
  caesarean section from those born vaginally.

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Low Birth Weight

• Infant delivered by cesarean section at 28 weeks
  gestation weighing 1700 grams.
• When low birth weight is due to prematurity
  select two codes from P07 Disorders related to
  short gestation and low birth weight, NEC.

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• P07.1 (M) Other low birth weight
• P07.3 (1) Other preterm infant
• Z38.01 (0) Singleton, born in hospital, delivered
  by cesarean section

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Low Birth Weight

• WHO guidelines state that priority of assignment
  should be given to birth weight.
• Birth weight of less than 2500 grams

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Respiratory Distress (RDS) vs Transient
Tachypnea (TTN)

• Newborn diagnosed with respiratory distress
  syndrome. Surfactant is not administered. Baby
  is discharged home on day 3.
• P22.1 Transient Tachypnea of Newborn.
• Z38.0 Singleton, born in hospital

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Standard for P22.0

• P22.0 Respiratory Distress Syndrome
• code when Surfactant is administered and
  diagnosis is documented as either RDS or TTN.
• Code when baby transferred to higher-level
  nursery or dies before Surfactant can be
  administered.

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Terminology

• APGAR American Pediatric Gross Assessment
  Record. It is a scoring system to estimate
  babys general condition at birth, at one minute
  and at five minutes
• Measures babys heart rate, breathing, muscle
  tone, reflex response and colour
• GTPAL Gravida Term Premature Abortion Live

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Classification based on MRDx

• MCC 14 Pregnancy and Childbirth
• Factors that impact CMG Assignment
• Complicating Cesarean Section
• Previous Cesarean Sections
• CMGs 600 - 624

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Classification based on MRDx

• MCC 15 Newborns and Neonates with Conditions
  originating in the perinatal period
• No complexity is assigned (level 9)
• Weight impacts CGM Assignment
• CMGs 625 - 648