Coding of vaginal deliveries requires a minimum of 3 codes; a principal diagnosis code, an outcome of delivery code and a weeks of gestation code. Fortunately, there are guidelines and notes to provide direction in properly assigning these codes. For delivery admissions, the principal diagnosis is the condition that prompted the admission.
Single live birth. Z37.0 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
Code O80 Encounter for full term uncomplicated delivery is assigned as the principal diagnosis for delivery admissions that meet the following criteria (ICD-10-CM Coding Guideline I.C.15.n): Vaginal delivery at full term No accompanying instrumentation (episiotomy is ok)
It’s interesting to note that if code O80 Normal delivery is assigned the principal dx for a delivery admission, code 10E0XZZ is this is the only appropriate ICD-10-PCS code to accompany that diagnosis. An assisted vaginal delivery is one that is accomplished with the assistance of instrumentation such as forceps or vacuum extraction.
Z37.0ICD-10 code Z37. 0 for Single live birth is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .
15. b. 4). Code O80 Encounter for full term uncomplicated delivery is assigned as the principal diagnosis for delivery admissions that meet the following criteria (ICD-10-CM Coding Guideline I.C.
Delivery requiring minimal or no assistance, with or without episiotomy, without fetal manipulation [e.g., rotation version] or instrumentation [forceps] of a spontaneous, cephalic, vaginal, full-term, single, live-born infant.
CPT® 59410, Under Vaginal Delivery, Antepartum and Postpartum Care Procedures. The Current Procedural Terminology (CPT®) code 59410 as maintained by American Medical Association, is a medical procedural code under the range - Vaginal Delivery, Antepartum and Postpartum Care Procedures.
Delivery requiring minimal or no assistance, with or without episiotomy, without fetal manipulation [e.g., rotation version] or instrumentation [forceps] of a spontaneous, cephalic, vaginal, full-term, single, live-born infant.
As a result the simple ICD-9-CM procedure code for labor induction, 73.4 (“Medical Induction of Labor”) has been replaced with the rather generic and opaque ICD-10-PCS procedure code: 3E033VJ (“Introduction of other hormone into peripheral vein, percutaneous approach”).
Each product of such a birth is considered live born. A live birth is any infant who breathes or shows any other evidence of live (such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles) after separation from the mother's uterus, regardless of the duration of gestation.
However, the term "live birth" was in common use long before 1950. In the United States, the term "born alive" is defined by federal law known as the born alive rule.
A stillbirth is when a fetus dies after the mother's 20th week of pregnancy. The baby may have died in the uterus weeks or hours before labor. Rarely, the baby may die during labor. Although prenatal care has drastically improved over the years, the reality is stillbirths still happen and often go unexplained.
The 59510 is for routine care and 59514 is delivery only.
The 0500F code is used for intital prenatal care visit with the provider. The 0501F is the prenatal flow sheet documented, which I do not use .
CPT® 59000, Under Antepartum and Fetal Invasive Services for Maternity Care and Delivery. The Current Procedural Terminology (CPT®) code 59000 as maintained by American Medical Association, is a medical procedural code under the range - Antepartum and Fetal Invasive Services for Maternity Care and Delivery.
ICD-10 code Z3A. 39 for 39 weeks gestation of pregnancy is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .
O82O82 - Encounter for cesarean delivery without indication. ICD-10-CM.
Obstetric cases require diagnosis codes from chapter 15 of ICD-10-CM, “Pregnancy, Childbirth, and the Puerperium.” It includes categories O00–O9A arranged in the following blocks:
Because certain obstetric conditions or complications occur during certain trimesters, not all conditions include codes for all three trimesters.
The obstetrics section is one of 16 sections in ICD-10-PCS and is categorized as one of the nine medical and surgical-related procedure sections. Similar to other ICD-10-PCS codes, obstetric procedure codes are seven characters in length with each of the seven characters representing an aspect of the procedure. The diagram above illustrates the seven characters of a code from the obstetrics section.
The assignment of the final character for trimester is based on the trimester for the current admission or encounter. This guideline applies to the assignment of trimester for pre-existing conditions as well as those that develop during or are due to the pregnancy.
Similar to ICD-9-CM, ICD-10-CM obstetric codes in chapter 15 have sequencing priority over codes from other chapters. Additional codes from other chapters may be used in addition to chapter 15 codes to further specify conditions.
Outcome of delivery codes (Z37.0–Z37.9) are intended for use as an additional code to identify the outcome of delivery on the mother’s records. These codes are not to be used on subsequent records or on the newborn record.
Codes from this category also require either a fifth or sixth character specifying the trimester. Code O30.0, Twin pregnancy, is further classified by whether the twin pregnancy is monoamniotic/monochorionic, conjoined twins, other twin pregnancy, or unspecified twin pregnancy.
Labor and delivery complicated by prolapse of cord, other fetus
Obstructed labor due to other malposition and malpresentation, not applicable or unspecified. Obstructed labor due to other malposition and malpresentation, fetus 1. Obstructed labor due to other malposition and malpresentation, fetus 2. Obstructed labor due to other malposition and malpresentation, fetus 3.
Obstructed labor due to incomplete rotation of fetal head, other fetus
Term delivery with preterm labor, third trimester, not applicable or unspecified
Term delivery with preterm labor, second trimester, not applicable or unspecified
Complications following (induced) termination of pregnancy (Code range- O04.5 – O04.89) – This includes the complications followed by abortions that are induced intentionally.
The Pregnancy ICD 10 code belong to the Chapter 15 – Pregnancy, Childbirth, and the Puerperium of the ICD-10-CM and these codes take sequencing priority over all the other chapter codes.
The chapter 15- Pregnancy, Childbirth, and the Puerperium codes can be used only to code the maternal records and never the newborn records.
Pre-existing hypertension complicating pregnancy, childbirth and the puerperium (Code range- O10.011-O10.93) – A pregnancy complication arising due to the patient being hypertensive, having proteinuria (increased levels of protein in urine), hypertensive heart disease, hypertensive CKD or both prior to the pregnancy.
Having a history of infertility, ectopic or molar pregnancies. Having a history of prior complicated pregnancy or pregnancies resulting in a pre-term delivery or a child with a genetic problem. Having a history of an in-utero procedure during previous pregnancy. Having social problems that is a threat to pregnancy.
Hydatidiform mole (Code range- O01.0 – O01.9) – Also known as molar pregnancy is an abnormal fertilized egg or a non-cancerous tumor of the placental tissue which mimics a normal pregnancy initially but later leads to vaginal bleeding along with severe nausea and vomiting.
Ectopic pregnancy (Code range- O00.00 – O00.91) – This is a potentially life-threatening condition in which the fertilize egg is implanted outside the uterus, usually in one of the fallopian tubes or occasionally in the abdomen or ovaries.