ICD-10-CM Quick Coding Reference for OB/GYN

Ingenix is now OptumInsight, part of Optum. www.optuminsightcoding.com ICD-10-CM Quick Coding Reference for OB/GYN

Contents Introduction Introduction ...... 1 The codes within ICD-9-CM fall woefully short of today’s medical reporting needs. In response to Diabetes ...... 3 ICD-9-CM’s shortcomings, new coding systems were developed and soon will be implemented in Multiple Gestation ...... 6 the United States. The World Health Organization (WHO) created and adopted ICD-10 in 1994, Pregnancy w/ Abortive Outcomes/ and it has been used in much of the world since then. This system is the basis for the new U.S. Abnormal Products of Conception ...... 10 diagnosis coding system, International Classification of Diseases, 10th Revision Clinical Inflammatory Diseases of Female Modification (ICD-10-CM). Pelvic Organs...... 13 STDs and Other Infections ...... 15 On January 16, 2009, the Department of Health and Human Services published a final rule Breast Disorders...... 19 adopting modifications to standard medical data code sets for coding diagnoses and inpatient Noninflammatory Disorders of hospital procedures by adopting ICD-10-CM for diagnosis coding, effective October 1, 2013. It Female Genital Tract ...... 22 also adopted the Official ICD-10-CM Guidelines for Coding and Reporting and ICD-10-PCS for Hypertension Complicating inpatient hospital procedure coding, with the same effective date. In February 2012, HHS Pregnancy, Childbirth, and the announced that it was delaying ICD-10-CM implementation to give health care providers more Puerperium ...... 23 time to prepare for implementation. The proposed effective date has been set for October 1, Malposition and Malpresentation 2013. of Fetus...... 27 Maternal Care Related to the Fetus and Amniotic Cavity and Possible How to Use the Quick Reference Delivery Problems...... 33 The Quick Reference helps users determine the most appropriate code for certain conditions commonly seen within particular specialties. Because it is a tool to help speed accurate code Published by: assignment, the reference cannot address all of the codes used by each specialty. Instead, this OptumInsight, Inc. tool focuses on some of the most challenging coding issues, using claims data and clinical 2525 Lake Park Blvd expertise to address those issues with both complex guidelines and/or multiple mappings. Salt Lake City, UT 84120 Tel 1.800.464.3649; Fax 801.982.4035 Because the reference is organized by condition, users can quickly see which categories of Product Manager: ICD-10-CM codes are used to report particular conditions. The reference includes: Mike Grambo ● Official coding guidelines to help understand the rules that are specific to certain conditions Technical Editors: Karen M. Adkins, CPC, CPC-I, CCS-P ● Documentation requirements for the most difficult coding challenges Nannette Orme, CPC, CPMA, CEMC ● Key terms for supporting code assignment I-10 Quick Coding Reference for OB/GYN is designed to provide accurate, authoritative ● ICD-9-CM-to-ICD-10-CM mapping for common conditions information. Every reasonable effort has been The “Terms to Know” section contains terms the user must understand to assign the correct code. made to ensure its accuracy. This report does not replace the ICD-9-CM coding manual. It This section is followed by the official coding guidelines that affect how a code is assigned. These serves only as a guide. guidelines are thoroughly explained in a short bulleted format, allowing the user to access necessary information quickly. Terms that support the use of a code are listed under the “Key © 2012 OptumInsight, Inc. All rights reserved. Terms” section. No part of the publication may be reproduced in any form without prior written permission of The last heading, “ICD-10-CM Mapping,” uses the general equivalence mappings (GEM) to allow the publisher in each instance. the user to see relationships established between the ICD-9-CM and ICD-10-CM code sets and the Our Commitment to Accuracy: OptumInsight is most likely code linkings. These mappings may have a one-to-one relationship or a one-to-many commited to producing accurate and reliable relationship. To ensure correct code selection, the user should carefully check official guidelines materials. To report corrections, please visit and medical record documentation. www.optumcoding.com/accuracy or email [email protected]. You can also reach Conventions Used in ICD-10-CM Mappings customer service by calling 1.800.464.3649, To use the mapping section appropriately, the user must understand the format, organization, option 1. and symbols used in the Quick Reference. OBQR12 Hypertension Complicating Pregnancy, Childbirth, and the Puerperium O10 Pre-existing hypertension complicating pregnancy, childbirth and the puerperium Key Terms: Hypertension O11 Pre-existing hypertension with pre-eclampsia Complicating Pregnancy, O13 Gestational [pregnancy-induced] hypertension without significant proteinuria Childbirth, and the Puerperium O14 Pre-eclampsia O15 Eclampsia Type O16 Unspecified maternal hypertension Benign Essential Term “benign” is becoming obsolete; the more common term is Terms to Know “essential” Elevated systemic arterial pressure with no known cause eclampsia. Tetany and toxemia producing seizure activity or coma in a pregnant patient who most often has presented with prior Secondary preeclampsia (i.e., hypertension, albuminuria, and edema). Eclampsia High blood pressure associated with a primary condition such as most commonly occurs during the third trimester or within the first 48 kidney, pulmonary, coronary, endocrine, or vascular diseases hours following birth. Transient hypertension. Abnormally increased pressure, usually referring to Term used to describe blood pressure that elevates temporarily but arterial pressure, exceeding an acceptable range. later returns to normal preeclampsia. Complication of pregnancy manifesting in the Pre-existing development of borderline hypertension, protein in the urine, and Condition that preceded the pregnancy; was already present unresponsive swelling between the 20th week of pregnancy and the end of the first week following birth in mild to moderate cases. Severe Gestational preeclampsia presents with hypertension, associated with marked Relating to the a condition that develops as the result of pregnancy swelling, proteinuria, abdominal pain, and/or visual changes. proteinuria. Abnormal quantities of serum proteins present in urine Manifestations that may subsequently indicate kidney damage. Hypertensive heart disease Heart problems that develop due to high blood pressure Guidelines Chronic kidney disease Gradual and frequent permanent loss of kidney function, most often ● Chapter 15 contains codes for conditions that existed prior to caused by hypertension and diabetes mellitus pregnancy as well as those that developed as a result of pregnancy; documentation should clearly denote whether the condition Pre-eclampsia being reported was a pre-existing condition or one that happened Classified accordingly by level based on blood pressure elevation and during or because of pregnancy to ensure correct code the other organs affected in the disease process: assignment. mild moderate ● Category O10 Pre-existing Hypertension Complicating Pregnancy, severe Childbirth and the Puerperium, contains codes that include HELLP syndrome: hypertensive heart and hypertensive chronic kidney disease; when acronym that stands for a group of symptoms occurring in one of these codes is reported, a secondary code must be assigned pregnancy that stands for hemolysis, elevated liver enzymes and to identify the specific type of heart failure or chronic kidney low platelet count disease. symptoms occur simultaneously with preeclampsia or may be ● When code categories do not distinguish between pre-existing or present prior to the patient becoming preeclamptic pregnancy-related conditions, any category can be used. It is also appropriate to assign codes specifically for the puerperium with codes designated as complicating pregnancy and childbirth if the Trimester condition occurs postpartum during the delivery encounter. First Less than 14 weeks and 0 days ● Final characters are reported for the majority of codes within chapter 15 designating the specific trimester of pregnancy; when Second trimester is not a component of a code, it is because trimester is not 14 weeks, 0 days to less than 28 weeks and 0 days applicable or the condition always occurs during a particular trimester. Note that there are a number of conditions that occur Third only in a certain trimester. The final character for trimester should 28 weeks and 0 days until delivery be based on documentation specifying the trimester or number of weeks of pregnancy at the time of the current encounter.

© 2012 OptumInsight, Inc. 23 Hypertension Complicating Pregnancy, Childbirth, and the Puerperium ICD-10-CM Mapping ICD-9-CM ICD-10-CM 642.00 BEN HTN COMP PG CHLDBRTH&THE PUERPERIUM UNS EOC O10.019 Pre-existing essential htn comp pregnancy, unsp trimester O10.919 Unsp pre-existing htn comp pregnancy, unsp trimester 642.01 BENIGN ESSENTIAL HYPERTENSION WITH DELIVERY O10.011 Pre-existing essential htn comp pregnancy, first trimester O10.012 Pre-existing essential htn comp pregnancy, second trimester O10.013 Pre-existing essential htn comp pregnancy, third trimester O10.02 Pre-existing essential hypertension complicating childbirth O10.911 Unsp pre-existing htn comp pregnancy, first trimester O10.912 Unsp pre-existing htn comp pregnancy, second trimester O10.913 Unsp pre-existing htn comp pregnancy, third trimester O10.92 Unsp pre-existing hypertension complicating childbirth 642.02 BEN ESSENTIAL HYPERTENSION W/DELIV W/CURRENT PPC O10.03 Pre-existing essential hypertension comp the puerperium 642.03 BENIGN ESSENTIAL HYPERTENSION ANTEPARTUM O10.011 Pre-existing essential htn comp pregnancy, first trimester O10.012 Pre-existing essential htn comp pregnancy, second trimester O10.013 Pre-existing essential htn comp pregnancy, third trimester O10.911 Unsp pre-existing htn comp pregnancy, first trimester O10.912 Unsp pre-existing htn comp pregnancy, second trimester O10.913 Unsp pre-existing htn comp pregnancy, third trimester 642.04 BENIGN ESSENTIAL HYPERTENSION PP COND/COMPL O10.03 Pre-existing essential hypertension comp the puerperium O10.93 Unsp pre-existing hypertension complicating the puerperium 642.10 HTN SEC RENL DZ COMPL PG BRTH&PP UNS EOC O10.419 Pre-existing secondary htn comp pregnancy, unsp trimester 642.11 HYPERTENSION SEC TO RENAL DISEASE WITH DELIVERY O10.411 Pre-existing secondary htn comp pregnancy, first trimester O10.412 Pre-existing secondary htn comp pregnancy, second trimester O10.413 Pre-existing secondary htn comp pregnancy, third trimester O10.42 Pre-existing secondary hypertension complicating childbirth 642.12 HTN SEC RENAL DISEASE W/DELIV W/CURRENT PP COMPL O10.43 Pre-existing secondary hypertension comp the puerperium 642.13 HYPERTENSION SEC TO RENAL DISEASE ANTEPARTUM O10.411 Pre-existing secondary htn comp pregnancy, first trimester O10.412 Pre-existing secondary htn comp pregnancy, second trimester O10.413 Pre-existing secondary htn comp pregnancy, third trimester 642.14 HTN SEC RENAL DISEASE POSTPARTUM COND/COMPL O10.43 Pre-existing secondary hypertension comp the puerperium 642.20 OTH PRE-XST HTN COMPL PG BRTH&PP UNS EOC O10.119 Pre-exist hyp heart disease comp pregnancy, unsp trimester O10.219 Pre-exist hyp chronic kidney disease comp preg, unsp tri O10.319 Pre-exist hyp heart and chr kidney dis comp preg, unsp tri O11.9 Pre-existing hypertension with pre-eclampsia, unsp trimester 642.21 OTHER PRE-EXISTING HYPERTENSION WITH DELIVERY O10.111 Pre-exist hyp heart disease comp pregnancy, first trimester O10.112 Pre-exist hyp heart disease comp pregnancy, second trimester O10.113 Pre-exist hyp heart disease comp pregnancy, third trimester O10.12 Pre-existing hypertensive heart disease comp childbirth O10.211 Pre-exist hyp chronic kidney disease comp preg, first tri O10.212 Pre-exist hyp chronic kidney disease comp preg, second tri O10.213 Pre-exist hyp chronic kidney disease comp preg, third tri O10.22 Pre-existing hyp chronic kidney disease comp childbirth O10.311 Pre-exist hyp heart and chr kidney dis comp preg, first tri O10.312 Pre-exist hyp heart and chr kidney dis comp preg, second tri O10.313 Pre-exist hyp heart and chr kidney dis comp preg, third tri O10.32 Pre-exist hyp heart and chronic kidney disease comp chldbrth O11.1 Pre-existing hypertension w pre-eclampsia, first trimester O11.2 Pre-existing hypertension w pre-eclampsia, second trimester O11.3 Pre-existing hypertension w pre-eclampsia, third trimester 642.22 OTH PRE-EXISTING HTN W/DELIV W/CURRENT PP COMPL O10.13 Pre-existing hypertensive heart disease comp the puerperium 642.23 OTHER PRE-EXISTING HYPERTENSION ANTEPARTUM O10.111 Pre-exist hyp heart disease comp pregnancy, first trimester O10.112 Pre-exist hyp heart disease comp pregnancy, second trimester O10.113 Pre-exist hyp heart disease comp pregnancy, third trimester O10.211 Pre-exist hyp chronic kidney disease comp preg, first tri O10.212 Pre-exist hyp chronic kidney disease comp preg, second tri O10.213 Pre-exist hyp chronic kidney disease comp preg, third tri O10.311 Pre-exist hyp heart and chr kidney dis comp preg, first tri O10.312 Pre-exist hyp heart and chr kidney dis comp preg, second tri O10.313 Pre-exist hyp heart and chr kidney dis comp preg, third tri O11.1 Pre-existing hypertension w pre-eclampsia, first trimester O11.2 Pre-existing hypertension w pre-eclampsia, second trimester O11.3 Pre-existing hypertension w pre-eclampsia, third trimester 642.24 OTH PRE-EXISTING HTN POSTPARTUM COND/COMPL O10.13 Pre-existing hypertensive heart disease comp the puerperium O10.23 Pre-existing hyp chronic kidney disease comp the puerperium O10.33 Pre-exist hyp heart and chr kidney disease comp the puerp 642.30 TRANSIENT HTN PREGNANCY UNSPEC AS EPIS CARE O13.9 Gestational htn w/o significant proteinuria, unsp trimester