Oh Baby! OB Coding For ICD-10-PCS - CMQCC

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Oh Baby! OB Codingfor ICD-10-PCSSponsored by1915 N. Fine Ave #104Fresno CA 93720-1565Phone: (559) 251-5038Fax:(559) 251-5836www.californiahia.orgProgram HandoutsTuesday, June 9, 2015Track One 1:00pm – 2:00pm2015 State Convention and ExhibitSpeakerKristi Pollard, RHIT, CCS, CPC, CIRCC,AHIMA-Approved ICD-10 TrainerCopyright California Health Information Association, AHIMA Affiliate

CHIA Convention & ExhibitJune 7-10, 2015 in Palm SpringsCalifornia HealthHealth InformationInformation AssociationAssociationCaliforniaOh Baby! OB Coding for ICD‐10‐PCSJune 9, 2015Kristi Pollard, RHIT, CCS, CPC, CIRCCSenior Coding ConsultantAHIMA Approved ICDAHIMA‐ApprovedICD‐10‐CM/PCS10 CM/PCS TrainerHaugen Consulting Groupkpollard@thehaugengroup.comDisclaimer This material is designed and provided to communicateinformation about clinical documentation,, coding,g, andcompliance in an educational format and manner. The author is not providing or offering legal advice but, rather,practical and useful information and tools to achievecompliant results in the area of clinical documentation, dataquality, and coding. Every reasonable effort has been taken to ensure that theeducational information provided is accurate and useful. Applying best practice solutions and achieving results will varyin each hospital/facility and clinical situation.CaliforniaHIA.orgCopyright California Health Information Association, AHIMA affiliate1

CHIA Convention & ExhibitJune 7-10, 2015 in Palm SpringsGoals/Objectives Differentiate between Medical and Surgical andObstetrical sections of ICD‐10‐PCSICD 10 PCS when codingfor pregnancy‐related procedures Determine the body system and body part forcoding obstetrical laceration repairs Utilize Coding Clinic advice for coding obstetricalcases Distinguish between the Extraction tables in theMedical and Surgical and Obstetrics sectionsCaliforniaHIA.orgProducts of Conception (POC)Any structure that isthe result of spermfertilizing an egg– Fetus– Placenta– Umbilical cord– Amniotic membrane– Amniotic fluid 2015 Haugen Consulting Group, Inc.CaliforniaHIA.orgCopyright California Health Information Association, AHIMA affiliate2

CHIA Convention & ExhibitJune 7-10, 2015 in Palm SpringsThree Variations of POCProducts of Conception Viable pregnancyProducts of Conception, Ectopic Displaced pregnancyProducts of Conception, Retained Nonviable pregnancy (e.g., spontaneous or missedabortion Postpartum retention of POCCaliforniaHIA.orgOB Procedures on Products ofConceptionCaliforniaHIA.orgCopyright California Health Information Association, AHIMA affiliate3

CHIA Convention & ExhibitJune 7-10, 2015 in Palm SpringsGuideline C1““Proceduresdperformedfd on theh productsdoffconception are coded to the Obstetrics section.Procedures performed on the pregnant femaleother than the products of conception arecoded to the appropriatepp proot operationpin theMedical and Surgical section.”CaliforniaHIA.orgOB ProceduresCaliforniaHIA.orgCopyright California Health Information Association, AHIMA affiliate4

CHIA Convention & ExhibitJune 7-10, 2015 in Palm SpringsDelivery Two possible root operations– Delivery “Catching the baby”– Extraction Cesarean deliveryVacuum extractionForceps extractionBreech extractionExtraction has multipleuses Not just delivery ofthe infant!– With or without internal versionCaliforniaHIA.orgDRG Alert!A delivery code from the OB section (10D/10E)must be coded to generate an delivery MS‐DRG!MS DRG!CaliforniaHIA.orgCopyright California Health Information Association, AHIMA affiliate5

CHIA Convention & ExhibitJune 7-10, 2015 in Palm SpringsDelivery (10E)The table with only one code!CaliforniaHIA.orgCesarean Section (10D)CaliforniaHIA.orgCopyright California Health Information Association, AHIMA affiliate6

CHIA Convention & ExhibitJune 7-10, 2015 in Palm SpringsVacuum‐Assisted C‐Section Coding Clinic, 4th Quarter2014 page 43:2014,– Vacuum extraction to assistcesarean section is includedin cesarean section code.The vacuum assistance isnot separately codedCaliforniaHIA.orgOther Assisted Delivery (10D)CaliforniaHIA.orgCopyright California Health Information Association, AHIMA affiliate7

CHIA Convention & ExhibitJune 7-10, 2015 in Palm SpringsQualifiers for Other Assisted Delivery Forceps delivery (3, 4, 5)– Qualifier specifiesplevel (low,( ,mid, high)– Not used for rotation of fetalhead without forceps deliveryLow ForcepsMid Forceps Rotation of fetal head only Reposition (10S07ZZ) Vacuum extraction ((6)) Breech extraction– With internal version (7)– Without internal version (8)Vacuum Extraction 2015 Haugen Consulting Group, Inc.CaliforniaHIA.orgEpisiotomy (0W8)Index Listing:Episiotomy ‐ see Division, Perineum, Female 0W8NDon’t code repair of episiotomyDo code repair of laceration that is an extension of anepisiotomy0W8NXZZCaliforniaHIA.orgCopyright California Health Information Association, AHIMA affiliate8

CHIA Convention & ExhibitJune 7-10, 2015 in Palm SpringsObstetrical Lacerations Code to the structure(s)involved Remember the guideline foroverlapping structuresB3.5“If the root operations Excision,Repair or Inspection areperformedfd on overlappingli layerslof the musculoskeletal system,the body part specifying thedeepest layer is coded.”CaliforniaHIA.orgObstetrical LacerationsLots of Coding Clinic advice! Fourth Quarter 2013,2013 page 120– Open approach is used for 2 laceration repair because thelaceration has exposed the muscle Fourth Quarter 2014, page 43–BBy definition,d fi itia 2 OB lacerationltiinvolves the muscle of the perineum Code to the body part Perineum, MuscleCaliforniaHIA.orgCopyright California Health Information Association, AHIMA affiliate9

CHIA Convention & ExhibitJune 7-10, 2015 in Palm SpringsFirst Degree Laceration Repair Repair of skin of perineum Build the code– Section Medical and Surgical (0)– Body System Skin and Breast (H)– Root operation Repair (Q)– Bodyy Part Skin, Perineum (9)( )– Approach External (X)0HQ9XZZRepairPerineumSkin,– Device No Device (Z)External Approach– Qualifier No Qualifier (Z)CaliforniaHIA.orgSecond Degree Laceration Repair of skin and muscle of the perineum Remember guideline B3.5B3 5– Build the code Section Medical and Surgical (0)Body System Muscles (deepest perineal layer) (K)Root operation Repair (Q)B d PartBodyP Muscle,M l PerineumP i(M)0KQM0ZZApproach Open (0)Repair Perineum Muscle,Device No Device (Z)Open ApproachQualifier No Qualifier (Z)CaliforniaHIA.orgCopyright California Health Information Association, AHIMA affiliate10

CHIA Convention & ExhibitJune 7-10, 2015 in Palm SpringsThird Degree Laceration Repair of 2 different body systems– Muscles Perineal muscle (deepest layer of perineum)– Gastrointestinal System Anal sphincter2 bodysystems 2codesCaliforniaHIA.orgThird Degree Laceration – First Code Build the code– Build the code Section Medical and Surgical (0)Body System Muscles (deepest perineal layer) (K)Root operation Repair (Q)Body Part Muscle, Perineum (M)Approach Open (0)Device No Device (Z)0KQM0ZZRepair Perineum Muscle,Qualifier No Qualifier (Z)Open ApproachCaliforniaHIA.orgCopyright California Health Information Association, AHIMA affiliate11

CHIA Convention & ExhibitJune 7-10, 2015 in Palm SpringsThird Degree Laceration – SecondCode Build the code– Section Medical and Surgical (0)– Body System Gastrointestinal System (D)– Root operation Repair (Q)– Body Part Anal Sphincter (R)– Approach Open (0)– Device No Device (Z)0DQR0ZZRepair Anal Sphincter, Open– Qualifier No Qualifier (Z)ApproachCaliforniaHIA.orgFourth Degree Laceration Repair of 2 different body systems– Muscles Perineal muscle (deepest layer of perineum)– Gastrointestinal System Documentation should specify structuresrepaired– Anal sphincter– Rectum– Anus Remember!– Guideline B3.5 applies to the musculoskeletal system,not GICaliforniaHIA.orgCopyright California Health Information Association, AHIMA affiliate12

CHIA Convention & ExhibitJune 7-10, 2015 in Palm SpringsFourth Degree Laceration – First Code Build the code– Section Medical and Surgical (0)– Body System Muscles (deepest perineal layer) (K)– Root operation Repair (Q)– Body Part Muscle, Perineum (M)– Approach Open (0)– Device No Device (Z)0KQM0ZZRepair Perineum Muscle,– Qualifier No Qualifier (Z)Open ApproachCaliforniaHIA.orgFourth Degree Laceration – AdditionalCodes Build the code––––Section Medical and Surgicalg((0))Body System Gastrointestinal System (D)Root operation Repair (Q)Specific code(s) depend onBody Part(s)documentation of repaired Anal Sphincter (R) Rectum (P) Anus (Q)– Approach Open (0)– Device No Device (Z)– Qualifier No Qualifier (Z)structures0DQR0ZZp Anal Sphincter,ppOpenRepairApproach0DQP0ZZRepair Rectum, Open Approach0DQQ0ZZRepair Anus, Open ApproachCaliforniaHIA.orgCopyright California Health Information Association, AHIMA affiliate13

CHIA Convention & ExhibitJune 7-10, 2015 in Palm SpringsOther OB Laceration Repairs Coding Clinic References– Fourth Quarter 2014, page 43 Periurethral laceration– “peri” guideline does not apply here– Body part vulva– Fourth QQuarter 2013,, ppageg 120 Clitoral laceration Repair of clitorisCaliforniaHIA.orgOther OB Lacerations Build the code––––Section Medical and Surgical (0)Body System Female Reproductive System (U)Root operation Repair (Q)Body Part(s) Vulva (periurethral) (M)Clitoris (J)Hymen (K)VaginaV i (G)– Approach External (X)– Device No Device (Z)– Qualifier No Qualifier (Z)Periurethral Repair0UQMXZZRepair Vulva, ExternalApproachCaliforniaHIA.orgCopyright California Health Information Association, AHIMA affiliate14

CHIA Convention & ExhibitJune 7-10, 2015 in Palm SpringsPitocin Administration Coding Clinic, Second Quarter 2014– DonDon’tt Code Pitocin augmentation Do Code Pitocin induction– Must know route of administration (e.g., peripheralvein)– Substance Hormone– Qualifier Other Hormone– 3E033VJ, Introduction of Other Hormone intoPeripheral Vein, Percutaneous ApproachCaliforniaHIA.orgCervidil/Cytotec Administration Coding Clinic, Second Quarter 2014– 3E0P7GC,3E0P7GC Introduction of other therapeuticsubstance into female reproductive, via natural orartificial opening3E0P7GC groups to a surgical MS‐DRG!CaliforniaHIA.orgCopyright California Health Information Association, AHIMA affiliate15

CHIA Convention & ExhibitJune 7-10, 2015 in Palm SpringsArtificial Rupture of Membranes Procedure intent: rupture membranes prior todelivery10907ZC Build the codeDrainage of Amniotic Fluid,Section Obstetrics (1)Therapeutic from POC, ViaOpeningBody System Pregnancy (0)Root Operation Drainage (9)Body Part Products of Conception (amniotic fluid ispart of POC) (0)– Approach Via Natural or Artificial Opening (most likely)(7)– Device No Device (Z)– Qualifier Amniotic Fluid, Therapeutic (C)––––CaliforniaHIA.orgAmniocentesis Procedure intent: drain fluid via needle from amniotic sacfor diagnostic or therapeutic purposes BuildB ild ththe codedSection Obstetrics (1)Body System Pregnancy (0)Root Operation Drainage (9)Body Part Products of Conception(amniotic fluid is part of POC) (0)– Approach–––– Percutaneous (3)– Device No Device (Z)– Qualifier 2015 Haugen Consulting Group, Inc. Amniotic Fluid, Diagnostic (U) Amniotic Fluid, Therapeutic (C)CaliforniaHIA.orgCopyright California Health Information Association, AHIMA affiliate16

CHIA Convention & ExhibitJune 7-10, 2015 in Palm SpringsFetal MonitoringInternal Fetal Monitoring Electrode placed internally(e.g., scalp electrode) Two codes:External Fetal Monitoring Electrode placed externally Fetal monitoring– 10H073Z, Insertion ofmonitoring electrode intoproducts of conception, vianatural or artificial opening– 4A1H7CZ, Monitoring ofproducts of conception,cardiac rate, via natural orartificial opening– 4A1HXCZ, Monitoring ofproducts of conception,cardiac rate, external approachCaliforniaHIA.orgIntrauterine Fetal Surgery Two root operations for procedures performedon the fetus in utero– Drainage (9) Fetal blood (9) Fetal Cerebrospinal Fluid (A) Fetal Fluid, Other (B)– Repair (Q) 2015 Haugen Consulting GroupGroup, Inc.Inc Repair of fetal defects in utero Qualifier specifies the fetal body system operated on– e.g., intrauterine repair of spina bifida (neural tube defect) –10Q08ZE, Repair nervous system in products of conception, vianatural or artificial opening endoscopicCaliforniaHIA.orgCopyright California Health Information Association, AHIMA affiliate17

CHIA Convention & ExhibitJune 7-10, 2015 in Palm SpringsOther OB ProceduresRetainedPP POCDUBD&CMAB/SABAbortionCaliforniaHIA.orgGuideline C2“Procedures performed following a delivery or abortionfor curettage of the endometrium or evacuation ofretained products of conception are all coded in theObstetrics section, to the root operation Extraction andthe body part Products of Conception, Retained.Diagnostic or therapeutic dilation and curettageperformed during times other than the postpartum orpost‐abortion period are all coded in the Medical andSurgical section, to the root operation Extraction and thebody part Endometrium.”CaliforniaHIA.orgCopyright California Health Information Association, AHIMA affiliate18

CHIA Convention & ExhibitJune 7-10, 2015 in Palm SpringsD&C – Choosing the Right SectionD&C of POC?NoYesMedical & SurgicalTo abort pregnancy?Extraction ‐endometriumYesNoAbortion – POCExtraction – POC,retainedCaliforniaHIA.orgAbortion vs. Extraction of Retained POCProcedure IntentTo treat missed or incompletespontaneous abortion(miscarriage)To terminate pregnancy(induced abortion)RootOperationExtractionAbortionBody PartProducts ofConception, RetainedProducts ofConceptionCaliforniaHIA.orgCopyright California Health Information Association, AHIMA affiliate19

CHIA Convention & ExhibitJune 7-10, 2015 in Palm SpringsPOC Extraction Building the code10D17ZZExtraction of products ofconception, retained, vianatural or artificialopening10D18ZZExtraction of products ofconception, retained, vianatural or artificialopening endoscopic– Section Obstetrics (1)– Body System Pregnancy (0)– Root Operation Extraction (D)– Body Part Products of Conception, Retained (1)– Approach Via Natural or Artificial Opening (7) Via Natural or Artificial Opening Endoscopic (8)– Device No Device (Z)– Qualifier No Qualifier (Z)CaliforniaHIA.orgCoding Clinic References Coding Clinic, Second Quarter, 2014, page 43:– D&C for removal of a blighted ovum using vacuum D&Ci codedisd d as EExtractioni off productsdoff conceptioni withihthe Qualifier Vacuum:– 10D07Z6, Extraction of products of conception, vacuum,via natural or artificial opening Coding Clinic, Second Quarter 2013, page 38:–PPost‐partum evacuationi off a bloodbl d clotl isi codedd d to thehMedical and Surgical section and root operationExtirpation:– 0UC97ZZ, Extirpation of matter from uterus, via naturalor artificial openingCaliforniaHIA.orgCopyright California Health Information Association, AHIMA affiliate20

CHIA Convention & ExhibitJune 7-10, 2015 in Palm SpringsAbortionDo Not use Abortion to codetreatment of a miscarriage!CaliforniaHIA.orgRemoval of Ectopic Pregnancy Procedure Intent: completely remove retained products ofconception Build the code–––––Section Obstetrics (1)Body System Pregnancy (0)Root Operation Resection (T)Body Part Products of Conception, Ectopic (2)Approach Open (0)Percutaneous (3) 2015 Haugen Consulting Group, Inc.Percutaneous Endoscopic (4)Via Natural or Artificial Opening (7)Via Natural or Artificial Opening, Endoscopic (8)– Device No Device (Z)– Qualifier No Qualifier (Z)CaliforniaHIA.orgCopyright California Health Information Association, AHIMA affiliate21

CHIA Convention & ExhibitJune 7-10, 2015 in Palm SpringsSummary Products of conception any structure or fluid that results from eggfertilization Procedures performed on POC code to the Obstetrical section; proceduresperformed on the mother code to the Medical and Surgical section Two root operations for delivery of an infant: Delivery and Extraction Episiotomy and obstetrical laceration repairs code to the Medical andSurgical section Remember Coding Clinic advice for OB laceration repairs! AROM and amniocentesis code to Drainage of POC D&C codes to Medical and Surgical or Obstetrical section, depending ontissue removed Root operation Abortion is for termination of pregnancy opyright California Health Information Association, AHIMA affiliate22

CHIA Convention & ExhibitJune 7-10, 2015 in Palm SpringsBibliography 2015 ICD‐10‐PCS Code Set and Guidelines:htt //http://www.cms.gov/Medicare/Coding/ICD10/M di/C di /ICD10/2015‐ICD‐10‐PCS‐and‐GEMs.html Coding Clinic for ICD‐10‐CM/PCS, AmericanHospital Association, Fourth Quarter 2012‐First QQuarter 2015CaliforniaHIA.orgCopyright California Health Information Association, AHIMA affiliate23

Oh Baby! OB Coding for ICD-10-PCS Sponsored by 1915 N. Fine Ave #104 Fresno CA 93720-1565 Phone: (559) 251-5038 Fax: (559) 251-5836 www.californiahia.org Program Handouts Tuesday, June 9, 2015 Track One 1:00pm - 2:00pm 2015 State Convention and Exhibit Speaker Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-Approved ICD-10 Trainer