The Complete Diagnosis Coding Book by Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 9 Coding Obstetrics and Gynecology Copyright © 2009 by The.

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The Complete Diagnosis Coding Book by Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 9 Coding Obstetrics and Gynecology Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved McGraw Hill/Irwin

Learning Outcomes ·Apply guidelines for coding all aspects of pregnancy. ·Determine the correct codes for reporting complications of pregnancy. ·Correctly report labor and delivery encounters

Learning Outcomes ·Distinguish between antepartum and postpartum conditions. ·Report the late effects of obstetric complications accurately. ·Explain the different types of abortive occurrences

Introduction ·Females of all ages may go to a gynecologist for specialized health care. ·Women who are pregnant are cared for by an obstetrician

Pregnancies ·Prenatal visits occur during pregnancy and are scheduled throughout the gestational period. ·These visits are predetermined, so they are code with V codes

Pregnancy Complications: Conditions and illnesses that ·threaten the pregnancy, ·threaten the health of the woman, or ·influence the treatment of the pregnancy

Pregnancy Fifth Digits: Complication codes: ·1 Delivered, with or without mention of an antepartum condition ·The woman gave birth to the baby at this encounter and she may or may not have a condition that complicated the pregnancy

Pregnancy ·Fifth Digits: Complication codes: ·2 Delivered, with mention of an postpartum condition ·The woman gave birth to the baby at this encounter and there is documentation of a problem that occurred afterward

Pregnancy Fifth Digits: Complication codes: ·3 Antepartum condition, not delivered ·The woman is still pregnant (she did NOT give birth at this encounter) and there is documentation of a complication

Pregnancy Fifth Digits: Complication codes: ·4 Postpartum condition ·The woman gave birth to the baby before this encounter and there is documentation of a problem that occurred after the birth

Preexisting Conditions ·Preexisting illnesses are coded differently when they complicate a woman’s pregnancy. ·These are most often systemic conditions

Gestational Conditions ·Conditions and illnesses that develop in a pregnant woman that are expected to resolve (go away) once the baby is born ·Examples: Gestational hypertension and Gestational diabetes

Fetal Conditions ·Any conditions identified in the fetus that affect the treatment of the mother during her pregnant state ·Example: Poor fetal growth may result in the mother being referred to a nutritionist

Labor and Delivery The encounter when the baby is born is reported with two codes: ·The actual delivery (the birth) ·Outcome of delivery (the baby)

Normal Delivery ·A spontaneous, full-term, vaginal, live-born, single infant ·No complications ·Use code 650 Normal delivery ·With V27.0 Single live-born

Delivery Anything else during delivery must be coded: · Multiple gestation ·Malposition of fetus ·Complications of delivery ·Cesarean delivery

Outcome of Delivery ·How many babies were born? ·Single, Twins, Triplets, and so on ·Live or stillborn ·Report with an Outcome of Delivery code: V27.x

Postpartum Conditions Routine Postpartum Conditions, just like routine prenatal or other types of care, are coded with V codes: ·V24.x Postpartum care and exam ·V24.0 Immediately after delivery ·V24.1 Lactating mother ·V24.2 Routine postpartum follow-up

Late Effects When a physician specifically identifies a condition with the mother as a ·Late effect of obstetric complications, report with ·677 Late effect of complication of pregnancy, childbirth, and the puerperium

Abortions An abortion may be ·spontaneous: caused by biological or natural triggers, or ·induced: caused by artificial or therapeutic sources

Abortions Abortive events may be ·unspecified, ·incomplete, or ·complete

Routine Gynecology Routine Gynecological Care is coded with V codes: ·V72.31 Routine gynecological exam ·V76.47 Special screening, vaginal ·V76.2 Special screening, cervix ·V25.x Contraceptive management

Other Testing ·V26.xx Procreative management ·V26.3x Genetic counseling and tests ·V72.4x Pregnancy exam or test ·V26.21 Fertility testing

Other Gynecology ·Endometriosis 617.0–617.9 ·Uterine fibroids 218.0–218.9 ·Pelvic pain 625.0–625.9 ·Sexually transmitted diseases ·Human papillomaviruses ·Gonorrhea 098.0– ·Genital wart ·Chlamydial infection 078.0– ·AIDS

Chapter Summary ·Female anatomy includes many organs and anatomical sites that can be subject to health concerns. ·During pregnancy, the health concerns are even greater and require more professional oversight