38.
ICD-10 code Z33. 1 for Pregnant state, incidental is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .
ICD-10-CM Code for Encounter for full-term uncomplicated delivery O80.
Encounter for supervision of normal pregnancy, unspecified90 Encounter for supervision of normal pregnancy, unspecified, unspecified trimester.
Encounter for supervision of normal pregnancy, unspecified, unspecified trimester. Z34. 90 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2022 edition of ICD-10-CM Z34.
ICD-10 code Z32. 01 for Encounter for pregnancy test, result positive is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .
Assign code O80, Encounter for full-term uncomplicated delivery, as the principal diagnosis. Codes Z3A. 40, 40 weeks of gestation of pregnancy, and Z37. 0, Single live born, should be assigned to describe weeks of gestation and the outcome of the delivery.
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 .
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 .
Encounter for supervision of other normal pregnancy80 Encounter for supervision of other normal pregnancy, unspecified trimester.
Code Z33. 1 This code is a secondary code only for use when the pregnancy is in no way complicating the reason for visit. Otherwise, a code from the obstetric chapter is required.
The only exception to this is if a pregnant woman is seen for an unrelated condition. In such cases, code Z33. 1 Pregnant State, Incidental should be used after the primary reason for the visit.
The only exception to this is if a pregnant woman is seen for an unrelated condition. In such cases, code Z33. 1 Pregnant State, Incidental should be used after the primary reason for the visit.
Code Z33. 1 This code is a secondary code only for use when the pregnancy is in no way complicating the reason for visit. Otherwise, a code from the obstetric chapter is required.
Z33. 1 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
ICD-10-CM: general coding and documentation If the pregnancy is incidental to an encounter for a different reason, code Z33. 1 (pregnant state, incidental) is assigned in place of any Chapter 15 codes.
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.
A high-risk pregnancy is a threat to the health and the life of the mother and the fetus.
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.
Complications following (induced) termination of pregnancy (Code range- O04.5 – O04.89) – This includes the complications followed by abortions that are induced intentionally.
Missed abortion (O02.1)- The retention of a non-viable fetus along with the placenta and embryonic tissues inside the uterus without the body recognizing the loss of pregnancy and therefore failing to naturally expel the non-viable contents like in spontaneous abortion.
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:
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.
Because certain obstetric conditions or complications occur during certain trimesters, not all conditions include codes for all three trimesters.
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.
They are defined as follows: First trimester: less than 14 weeks 0 days. Second trimester: 14 weeks 0 days to less than 28 weeks 0 days. Third trimester: 28 weeks 0 days until delivery.
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.
At 28 weeks, the patient is in her third trimester. According to the notes at the beginning of the chapter, code Z3A.28, 28 weeks gestation of pregnancy, should also be reported. These codes are located in the index with the main term Pregnancy, subterm weeks of gestation.
A pregnancy at 14 weeks and 2 days is considered to be in the first trimester.
Refer to the index main term Pregnancy, subterms weeks of gestation, 30 weeks (Z3A.30). Verify in the tabular list and assign Z3A.30, 30 weeks' gestation of pregnancy. Supervision of a high-risk pregnancy is required in the third trimester due to inadequate prenatal care.
The coding and sequencing should be Asthma, allergic extrinsic, with status asthmaticus, J45.902. The code for wheezing is not reported because it is a common symptom of an asthma attack, and an Excludes1 Note for wheezing is present in the tabular list.
Code R29.6, Repeated falls, is for use for encounters when a patient has recently fallen and the reason for the fall is being investigated. Code Z91.81, History of falling, is for use when a patient has fallen in the past and is at risk for future falls.
Functional quadriplegia is defined as the complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the brain or spinal cord. Amyotrophic lateral sclerosis is a progressive neurological disease.
According to the guidelines, symptom code G89.3, Neoplasm related pain, would be selected as the principal diagnosis, followed by a code for liver cancer.
There are O codes indicating that a condition in any other body system is impacting the pregnancy. If the rest of Chapter 15 doesn’t have a specific code, numerous “obstetric conditions not elsewhere classified which are complicating pregnancy, childbirth, and the puerperium” can be found in O94-O9A.
If there is no indication (or more precisely, no medical indication –“OB going on vacation next week” probably isn’t really a legitimate indication), “O82, Encounter for cesarean delivery without indication” is the code.
The last pieces of information that should be on every record with a delivery are an outcome of delivery code from Z37 and a listing of weeks of gestation designation from Z3A. The exception to this is when a patient delivers prior to admission to the hospital. In that case, you only use Z39.0, Encounter for care and examination of mother immediately after delivery, since she didn’t actually deliver during this admission and wasn’t technically pregnant during this admission.
Did complications arise during the delivery or in the postpartum period (defined as from delivery to six weeks post-term)? “Puerperium” means the period between childbirth and the return of the uterus to its normal size. Be sure to select the correct code that designates trimester in childbirth (during labor), or in puerperium (postpartum).
The key is to think about how the situation unfolded and to be able to compliantly code it. This may take querying of a group of providers who we really never asked anything of before, and who will need some training as to how to respond.
As an example, a patient in the third trimester who was involved in a motor vehicle collision and brought in for observation who went on to deliver would warrant the “O9A.22, Injury, poisoning, and certain other consequences of external causes complicating childbirth” code. You then would add the codes that told the remainder of the story: what was injured, the circumstances of the incident, the outcome of the delivery, how many weeks pregnant she was, how she delivered, whether there any other complications, etc.
In that case, you only use Z39.0, Encounter for care and examination of mother immediately after delivery, since she didn’t actually deliver during this admission and wasn’t technically pregnant during this admission.
Between 50% and 70% of patients will go into labor within 48 hours. In 80% to 90% of cases, labor begins within 24 hours if the gestational age is near term. However, if gestational age is less than 36 weeks, only 35% to 50% of cases will spontaneously begin labor within 24 hours. Assign a code from category O42 .
Preterm labor is the presence of contractions occurring before 37 completed weeks of gestation, of sufficient strength and frequency to effect progressive effacement and dilation of the cervix.
Obstetrical discharges represent a significant portion of the abstracts in the Discharge Abstract Database (DAD). Obstetrical patients are unique from other acute care patients in hospital as they are not “sick” per se. This makes the coding and assignment of diagnosis typing in the obstetrical population somewhat different from that of the general population. To add to this, documentation is often a problem on obstetrical charts — lack of a diagnostic statement, conflicting information, inappropriate application of definitions, etc. For these reasons, the selection of codes for obstetrics is often based on criteria as set out in the
The term “irritable uterus” is typically used to describe irregular contractions that occur during pregnancy prior to the onset of labor. These contractions are usually an indication of Braxton- Hicks contractions (the uterine muscle practising for labor) or they may indicate labor contractions that, left untreated, may lead to delivery. As long as these contractions are not affecting the cervix there is no risk of preterm labor (i.e., this would be false labor).
These contractions, also called BraxtonHicks - contractions, tone the uterus in preparation for true labor. Braxton-Hicks contractions are a common cause of false labor.
The term “irritable uterus” is typically used to describe irregular contractions that occur during pregnancy prior to the onset of labor. These contractions are usually an indication of Braxton-Hicks contractions (the uterine muscle practising for labor) or they may indicate labor contractions that, left untreated, may lead to delivery. As long as these contractions are not affecting the cervix there is no risk of preterm labor (i.e., this would be false labor).
False labor is defined as ineffective contractions that resemble labor pains but are not accompanied by effacement and dilation of the cervix. Unlike the contractions of true labor, these contractions are irregular and follow no discernible pattern. They are non-progressive; they don’t become stronger, longer or more frequent. These contractions, also called Braxton-Hicks contractions, tone the uterus in preparation for true labor. Braxton-Hicks contractions are a common cause of false labor.2