NTSV: Accurate Coding for Improved Quality Measures Program III: OB Procedure Coding Module 3: Delivery and Procedures Assisting Delivery Grant Acknowledgement Funding for this training series was made possible by a sub- award from the American College of Obstetricians and Gynecologists under Grant #UC4MC28042 from the Health Resources and Services Administration. The views expressed in the written materials and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government. Resource Acknowledgement Information presented in this module is directly resourced from the 2020 ICD-10-CM/PCS Official Guidelines for Coding and Reporting found on the Centers for Disease Control and Prevention website and the ICD-10-CM and ICD-10-PCS Coding Handbook With Answers published by the American Hospital Association. Our Faculty Carole Liebner, RHIT, CDIP, CCS AHIMA APPROVED ICD-10-CM/PCS TRAINER AHIMA APPROVED REVENUE CYCLE TRAINER Director, Education & Program Development Amber Owens, RHIA, CICA, CCS Director of Health Information Services Program III: Module 3 Topics Review delivery and the procedures assisting delivery. Take a look at manually assisted delivery. Describe C-section delivery. Illustrate vacuum assisted and forceps deliveries. Demonstrate perineal lacerations and episiotomies. And a little assessment at the end to test your knowledge. Delivery Delivery: Assisting the passage of the products of conception from the genital tract. Classified to the Obstetrics Section: Root operation: Delivery Body system: Pregnancy 10E0XZZ: Delivery of products of conception, external approach C-Section Surgical delivery performed when vaginal delivery is not possible or advisable. Classified to the Obstetrics Section: Root operation: Extraction Body system: Pregnancy 10D00Z_: Delivery of products of conception, external approach C-Section Qualifier High: an incision through the mother’s lower abdomen. A second incision is made in the uterus from which the baby is removed Classic/Vertical Low: a procedure in which a baby is delivered through a transverse incision in the thin supracervical part of the lower uterine segment, an area located behind the bladder and the bladder flap Low Transverse/Horizontal/Bikini-line C-Section Qualifier Extraperitoneal: an incision is made in the lower uterine segment that does not require entering the peritoneal cavity. With this method, the uterus is approached through the paravesical space and the baby, placenta, and membranes are all removed via the uterus incision. C-Section Root Operation Cesarean deliveries are coded to the Obstetrics Section to the root operation “Extraction.” The root operation “Extraction” is also used for vaginal deliveries requiring assistance with forceps, vacuum, or internal version. Occasionally, vacuum assistance is used with cesarean delivery. However, the use of the vacuum is not separately coded. Assign only the PCS code for the cesarean delivery. Forceps & Vacuum Forceps Extraction Forceps assisted delivery: Coded to the Obstetrics Section Root operation Extraction Low-forceps (seventh-character qualifier value 3) Mid-forceps (seventh-character qualifier value 4) High-forceps (seventh-character qualifier value 5) Forceps Delivery Low Forceps: an obstetric operation in which forceps are used to deliver a baby whose head is on the pelvic floor. Mid Forceps: an obstetric operation in which forceps are applied to the baby's head when it has reached the midplane of the mother's pelvis. An episiotomy will likely accompany a mid forceps delivery. High Forceps: an obstetric procedure in which forceps are used to deliver a baby whose head is not engaged in the birth canal. Vacuum Extraction Vacuum-assisted delivery: Coded to the Obstetrics Section. Root operation: Extraction Vacuum extraction (seventh-character qualifier value 6). Use of a traction device rather than forceps. Table 10D Episiotomy Episiotomy is a Episiotomy with An episiotomy can surgical incision in forceps delivery extend to become a the perineum, requires two perineal laceration enlarging the codes: or tear. Assign a code for the vaginal opening to Code forceps assist delivery. delivery as well episiotomy along as the episiotomy. with a code for Episiorrhaphy repair of perineal (repair) is not laceration. coded separately, it is integral to the procedure. Perineal Lacerations Obstetric perineal lacerations occur within the supportive layer of tissue between the vaginal introitus and the rectum commonly called the perineum. The perineal body marks the point where the perineal muscles converge. The outermost layer (skin) of the perineum may only be involved or the tear can extend into the muscles of the perineal body. It can also continue into the anal sphincter and the mucosal layers of the anus and rectum. Degrees of Lacerations First degree: Involving the perineal skin and its extension into the vagina as vaginal mucosa. Second degree: Involving the perineal body and deeper tissues. Third degree: Extending into the capsule and muscle of the anal sphincter. Fourth degree: Extending through the sphincter and into the anal/rectal mucosa. 1st Degree Laceration First-degree perineal laceration First-degree tears involve injury to the outermost layer of the perineum and vaginal mucosa. Assign code 0HQ9XZZ: Repair perineum skin, external approach, for repair of a first degree perineal laceration. 2nd Degree Laceration Second-degree perineal laceration Second-degree tears include injury to the vaginal wall and perineal muscle, but do not extend down into the anal sphincter muscle. Assign code 0KQM0ZZ: Repair perineum muscle, open approach, for repair of a second degree perineal laceration. 3rd Degree Laceration Third-degree perineal laceration Third-degree tears extend to the anal sphincter, but the anal/rectal mucosa beneath the anal sphincter are intact. An anal sphincter tear can involve less than 50% external anal sphincter thickness, more than 50% external anal sphincter thickness, or both external and internal anal sphincter. Assign code 0DQR0ZZ: Repair anal sphincter, open approach, for repair of a third degree perineal laceration. 4th Degree Laceration Fourth-degree perineal laceration Fourth-degree tears consist of injury to the perineum, and the anal sphincter complex (external anal sphincter and internal anal sphincter), and the rectal mucosa. Assign code 0DQP0ZZ: Repair rectum, open approach, for the repair of the fourth-degree tear. Amnioinfusion Administration Section Root operation: Introduction Used for: Prophylactic treatment of oligohydramnios. Reduction of variable decelerations of fetal heart rate. Treatment of preterm premature rupture of membranes. Fetal Heart Monitoring External fetal monitoring: 4A1HXCZ: Monitoring of products of conception, cardiac rate, external approach. Internal fetal monitoring: 4A1H7CZ: Monitoring of products of conception, cardiac rate, via natural or artificial opening. Assessment Question 1 When is it appropriate to assign the root operation Delivery? a. Every time a baby is born b. Manually Assisted Vaginal Birth c. Termination of Pregnancy d. When forceps are used Question 1 - Answer When is it appropriate to assign the root operation Delivery? a. Every time a baby is born b. Manually Assisted Vaginal Birth c. Termination of Pregnancy d. When forceps are used Question 2 Cesarean deliveries are coded to the Obstetrics Section to the root operation: a. Delivery b. Excision c. Control d. Extraction Question 2 - Answer Cesarean deliveries are coded to the Obstetrics Section to the root operation: a. Delivery b. Excision c. Control d. Extraction Question 3 True/False: The repair of an obstetric perineal laceration is coded based on the degree of the tear and the tissue repaired. Question 3 – True When more than one degree is mentioned, only the code for the highest degree is assigned. Question 4 In a perineal laceration, when more than one degree of laceration is documented, assign a code for: a. The lowest degree mentioned b. The highest degree mentioned c. Don’t assign a code, it’s too confusing d. Assign a code for every degree mentioned Question 4 - Answer In a perineal laceration, when more than one degree of laceration is documented, assign a code for: a. The lowest degree mentioned b. The highest degree mentioned c. Don’t assign a code, it’s too confusing d. Assign a code for every degree mentioned Question 5 When an episiotomy extends to become a perineal laceration, ICD-10-PCS codes are assigned for: a. The episiotomy only b. The laceration repair only c. The delivery and the laceration repair d. The episiotomy, the laceration repair and the delivery Question 5 - Answer When an episiotomy extends to become a perineal laceration, ICD-10-PCS codes are assigned for: a. The episiotomy only b. The laceration repair only c. The delivery and the laceration repair d. The episiotomy, the laceration repair and the delivery Question 6 True/False: When a vacuum is used to assist a C-section delivery it is appropriate to code both the vacuum and the C-section. Question 6 - False Occasionally, vacuum assistance is used with cesarean delivery. However, the use of the vacuum is not separately coded. Assign only the PCS code for the cesarean delivery. References ICD-10-CM Official Guidelines for Coding and Reporting FY 2020. (2020). Centers