Obstetrical & Gynecological Tip Sheet for ICD-10

Diagnosis Documentation Requirements

Document specific Document: Abdominal Pain location: - Acute abdominal pain - RUQ - LUQ - Abdominal tenderness - RLQ - LLQ - Rebound abdominal pain - Periumbilic - Epigastric - Generalized Document Type: Document cause: Document any alcohol or Anemia - Nutritional deficiency (iron, - Neoplastic disease drug use, abuse, Vit B12, foliate, protein, etc.) - Chronic kidney disease dependence or past - Hemolytic (enzyme disorder, history thalassemia, etc.) Document underlying cause - Sickle cell (with or without if known: Specify name of medication crisis) with acute chest - Postoperative anemia due or drug with purpose of its syndrome or splenic to acute blood loss use sequestration, etc.) - Blood loss (acute, chronic, postoperative) Document: Anxiety - Generalized anxiety - Mixed anxiety - Panic w/o agoraphobia Document specific site: Specify site of panniculitis or Specify site of panniculitis or Back Pain - Low back radiculopathy: radiculopathy: - Thoracic - Thoracolumbar - Occipito-atlanto-axial - Cervical - Lumbar - Cervical - Lumbosacral - Cervicothoracic Document the underlying - Sacral and scrococcygeal - Thoracic cause: - Multiple sites - Herniated disc - Radiculopathy - Fracture Document: Document: insulin Differentiate: Diabetes Mellitus - Type I or Type II underdosing or overdosing - Diabetes accompanied by - Long-term insulin use for related to insulin pump hypoglycemia OR Type II malfunction hyperglycemia

Document any cause/effect Document any underlying Document: relationship between diabetes condition, drug or chemical - Hypoglycemia with OR and other conditions (e.g. PVD, responsible for Secondary without coma Ulcer, Neuropathy, etc.) Diabetes (e.g., steroid induced) Document Type: Document reason Drug Underdosing - Intentional versus for underdosing, - Unintentional such as: - Financial hardship Or - Age related dementia Specify: - Primary - Secondary Document any associated Specify urinary symptoms Identify signs and symptoms conditions: that are not routinely Dysuria associated with benign - Urinary incontinence prostatic hyperplasia associated with or integral to - Overactive bladder (BPH) a disease process - Nocturia - Hesitancy - Retention - Weak stream

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Obstetrical & Gynecological Tip Sheet for ICD-10

Diagnosis Documentation Requirements

Differentiate: Differentiate: Differentiate: - Routine gynecological exam Examination - Adult annual exam w/o - Pre-employment exam abnormal findings - Admission to school w/o abnormal findings - Adult annual w/ abnormal exam - Routine gynecological exam findings w/ abnormal findings - Participation in sport - Exam of blood pressure w/o abnormal findings - Exam of blood pressure w/ abnormal findings Document timing: Document trimesters False Labor - Before 37 weeks - At or after 37 weeks Document specific site: Fibroids/Leiomyoma - Submucous - Intramural - Subserosal Document: Delineate if only abnormal Gestational - Pre-existing Type l glucose tolerance test - Pre-existing Type ll without diagnosis of Diabetes - Diet controlled Gestational diabetes Diabetes - Insulin controlled Gestational Diabetes Document gestational edema and proteinuria with and Gestational without gestational Hypertension hypertension Versus Gestational - Findings of edema and Edema and proteinuria explain increase in number of office visits and Proteinuria without complexity of patient you are Hypertension treating If a condition or injury being Example: Pregnant If the physician does not treated in a pregnant patient state the burn does not Incidental Pregnant patient with burn of hand: is not affecting or - If physician states the affect or complicate the State versus complicating the pregnancy, it burn does not affect or pregnancy: is the physician’s - A code for an obstetrical Complication of complicate the pregnancy, responsibility to state this, complication is assigned Pregnancy code Z33.1, Pregnant otherwise a code is assigned state, incidental, is that states obstetric complication. assigned along with a code for the burn. Document site: Document organism, Infections of the - Bladder when known: - Kidney - Bladder infection due to Genitourinary Tract - E. coli Document type: Document type: Document Type: Leukocytosis - Lymphocytois - Basophilia -Bandemia - Monocytosis - Leukemoid reaction -Other - Plasmacytosis Document episode: Document severity: Indicate status: Major Depressive - Single - Mild -Full remission - Recurrent - Moderate -Partial remission Disorder - Severe w/o psychotic symptoms - Severe w/psychotic symptoms Document Type, such as: Document severity: Document BMI - Protein calorie - Mild or 1st degree Malnutrition nd - Protein energy - Moderate or 2 degree - Severe or 3rd degree

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Obstetrical & Gynecological Tip Sheet for ICD-10

Diagnosis Documentation Requirements

Specify: Specify: Specify: Menstrual Bleeding - Primary/Secondary - Menorrhagia - Irregular - / - Intermenstrual (ovulatory) - Primary/Secondary Menorrhagia - Post-menopausal - Excessive at puberty - Excessive premenopausal Multiple Gestation Document, for twins: Document, for triplets, - monochorionic/ quadruplets and other: monoamniotic - With two or more - Monochorionic/diamniotic monochorionic fetuses - Dichorionic/diamniotic - With two or more Or monoamniotic fetuses - Unable to determine number Or of placenta and number of - Unable to determine amniotic sacs number of placenta and number of amniotic sacs Document site and laterality, Differentiate between: For secondary sites: Neoplasms such as: - Primary Document primary site and if - Ectocervix - Secondary (metastatic) site it is still present - Left ovary Document etiology: If morbidly obese, also Document BMI Obesity - Due to excess calories or document if with alveolar nutritional hypoventilation - Due to drugs - Other, for example, due to thyroid or pituitary disorder Obstructed Labor Document malposition or Document maternal pelvic Document other cause, such malpresentation, such as: abnormality, such as: as: - Incomplete rotation of head - Deformed - Shoulder dystocia - Breech, face, brow, shoulder, - Contraction - Unusually large fetus or compound presentation - General contracted, pelvic - Other, such as footing or inlet, pelvic outlet, mid-cavity incomplete breech - Abnormality of pelvic organ, presentation e.g., congenital malformation of or cervical incompetence Indicate the presence of Document encounter type: Document healing status: Osteoporosis current pathological fractures - Initial - Routine - Subsequent - Delayed Identify the current fracture site - Sequela - Nonunion - Malunion Document any major osseous defect Pre-eclampsia Document severity: - Mild - Moderate Or - Severe Pre-existing versus Pregnancy Document whether a Induced Conditions condition is pre-existing or pregnancy induced: - Hypertension - Diabetes All OB records must include Document visit type: Document reason for high risk Pregnancy pregnancy as stated in - Supervision normal pregnancy (i.e. h/o , weeks AND trimester: pregnancy h/o ectopic, insufficient - <14 weeks 0 days = First - Supervision of high risk prenatal care, etc.) Trimester pregnancy - 14.1 weeks to 28 weeks = Second trimester - 28.1 weeks until delivery = Third trimester

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Obstetrical & Gynecological Tip Sheet for ICD-10

Diagnosis Documentation Requirements

Document state of Document if used Document type: dependence: during pregnancy, Tobacco Use Disorder - Cigarettes - In remission - Chewing tobacco childbirth, and - With withdrawal - Other puerperium - Without withdrawal

Delineate between: Describe history, including product and time - Tobacco use/abuse

- Tobacco dependence Document Site: Document if UTI is related to Do NOT use the term Urinary Tract Infection (UTI) - Bladder a device, such as: UROSEPSIS - Urethra - Foley Catheter (consider UTI with Sepsis) - Kidney - Cystostomy tube

Document: Causative organism, if known Delineate: Document causative agent: - Acute vaginitis (Bacterial - of and vaginosis) vagina - Subacute and chronic vaginitis - Trichomonal vulvovaginitis - Acute vulvitis - Streptococcus Group A - Subacute and chronic vulvitis - Streptococcus Group B - Ulceration of vagina - Enterococcus - Ulceration of vulva - Staphylococcus Methicillin susceptible - Staphylococcus Methicillin resistant Procedures Documentation requirements Document type: C-Section - Classical - Extraperitoneal - Low cervical Manual Assisted Document any accompanying Delivery procedures: - AROM - Episiotomy - Evacuation of hematoma - Induction of labor - Ob laceration repair Medical Induction of Document: Labor - Pitocin - Artificial rupture of membranes - Dilation of cervix Repair OB Laceration Document site of repair: Document degree of Document laterality: - Anal or rectal mucosa laceration: - Right - Bladder or urethra - 1st - Left - 2nd - Cervix - Bilateral - Perineal - 3rd - Uterus - 4th - Vaginal wall - Vulva Total Abdominal Document approach: Document any additional Hysterectomy - Open resection done: - Percutaneous - Fallopian tubes - Percutaneous endoscopic - Ovary - Pelvic lymph nodes Document purpose: Document approach: Vacuum Extraction - Delivery - Open (cesarean section) - Ectopic - Via natural or artificial - Retained opening

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