1. 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

2. 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. 9 - 2

3. Learning Outcomes ·Distinguish between antepartum and postpartum conditions. ·Report the late effects of obstetric complications accurately. ·Explain the different types of abortive occurrences. 9 - 3

4. Introduction ·Females of all ages may go to a gynecologist for specialized health care. ·Women who are pregnant are cared for by an obstetrician. 9 - 4

5. Pregnancies ·Prenatal visits occur during pregnancy and are scheduled throughout the gestational period. ·These visits are predetermined, so they are code with V codes. 9 - 5

6. Pregnancy Complications: Conditions and illnesses that ·threaten the pregnancy, ·threaten the health of the woman, or ·influence the treatment of the pregnancy. 9 - 6

7. 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. 9 - 7

8. 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. 9 - 8

9. 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. 9 - 9

10. 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. 9 - 10

11. Preexisting Conditions ·Preexisting illnesses are coded differently when they complicate a woman’s pregnancy. ·These are most often systemic conditions. 9 - 11

12. 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 9 - 12

13. 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. 9 - 13

14. 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) 9 - 14

15. Normal Delivery ·A spontaneous, full-term, vaginal, live-born, single infant ·No complications ·Use code 650 Normal delivery ·With V27.0 Single live-born 9 - 15

16. Delivery Anything else during delivery must be coded: · Multiple gestation ·Malposition of fetus ·Complications of delivery ·Cesarean delivery 9 - 16

17. 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 9 - 17

18. 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 9 - 18

19. 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. 9 - 19

20. Abortions An abortion may be ·spontaneous: caused by biological or natural triggers, or ·induced: caused by artificial or therapeutic sources. 9 - 20

21. Abortions Abortive events may be ·unspecified, ·incomplete, or ·complete. 9 - 21

22. 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 9 - 22

23. Other Testing ·V26.xx Procreative management ·V26.3x Genetic counseling and tests ·V72.4x Pregnancy exam or test ·V26.21 Fertility testing 9 - 23

24. Other Gynecology ·Endometriosis 617.0–617.9 ·Uterine fibroids 218.0–218.9 ·Pelvic pain 625.0–625.9 ·Sexually transmitted diseases ·Human papillomaviruses 079.4 ·Gonorrhea 098.0–098.89 ·Genital wart 078.19 ·Chlamydial infection 078.0–079.99 ·AIDS 042 9 - 24

25. 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. 9 - 25