New and Revised ICD-10-CM Obstetric Guidelines

By Ann Barta, MSA, RHIA, CDIP

When comparing the ICD-9-CM and ICD-10-CM obstetric guidelines, coding professionals should note both revised and completely new guidelines in ICD-10-CM. These guidelines are a result of various new concepts introduced in Chapter 15 of ICD-10-CM, such as the addition of a seventh character to identify the fetus in a multiple gestation affected by the condition being coded. Some of these new and revised ICD-10-CM obstetric guidelines are highlighted below.

I.C.15.a.3. Final Character for Trimester

This new ICD-10-CM guideline for the final character indicates that many of the Chapter 15 codes specify the trimester of the pregnancy. A note at the beginning of Chapter 15 defines the timeframes for the three trimesters. The assignment of the final character for trimester is based on either the provider's documentation of the trimester—or the number of weeks of gestation—for the current admission/encounter.

For example, the following list illustrates how the final character in coding for an obstetric condition may provide further specification:

• O11.1, Pre-existing hypertension with pre-eclampsia, first trimester
• O11.2, Pre-existing hypertension with pre-eclampsia, second trimester
• O11.3, Pre-existing hypertension with pre-eclampsia, third trimester
• O11.9, Pre-existing hypertension with pre-eclampsia, unspecified trimester

The final character guideline further states that whenever a delivery occurs during the current admission, and there is an "in childbirth" option for the obstetric complication being coded, the "in childbirth" code should be assigned.

For example, the obstetric complication of pre-existing diabetes mellitus, type 2 should be coded to "in childbirth" if the patient delivers during the current admission:

O24.111, Pre-existing diabetes mellitus, type 2, in pregnancy, first trimester

• O24.112, Pre-existing diabetes mellitus, type 2, in pregnancy, second trimester
• O24.113, Pre-existing diabetes mellitus, type 2, in pregnancy, third trimester
• O24.119, Pre-existing diabetes mellitus, type 2, in pregnancy, unspecified trimester
• O24.12, Pre-existing diabetes mellitus, type 2, in childbirth
• O24.13, Pre-existing diabetes mellitus, type 2, in the puerperium

The following code assignment illustrates the coding of the above two conditions for a patient that delivers during the current encounter and is at 39 weeks of gestation:

• O11.3, Pre-existing hypertensive with pre-eclampsia, third trimester
• O24.12, Pre-existing diabetes mellitus, type 2, in childbirth

I.C.15.a.4. Selection of Trimester for Inpatient Admissions that Encompass More than One Trimester

This new guideline for selection of trimester for inpatient admissions that encompass more than one trimester is applicable for those situations in which a patient is admitted to the hospital for pregnancy complication(s) during one trimester and remains in the hospital into a subsequent trimester. In this situation, the trimester character for the antepartum complication code should be assigned based on the trimester when the complication developed, not the trimester of discharge. If the condition developed prior to the current admission/encounter or represents a pre-existing condition, the trimester character for the trimester at the time of the admission/encounter should be assigned.

For example, a patient at 27 weeks and five days gestation is admitted to the hospital with complications from a bladder infection and pre-existing essential hypertension. The patient is treated and remains in the hospital for four days. The patient is 28 weeks and two days gestation at the time of discharge. The correct code assignment for the two complications is:

• O23.12, Infection of bladder in pregnancy, second trimester
• O10.012, Pre-existing essential hypertension complicating pregnancy, second trimester

I.C.15.a.6 Seventh Character for Fetus Identification

Certain categories in Chapter 15 require that a seventh character is assigned to identify the fetus in a multiple gestation for which the complication code applies. The seventh character values for Chapter 15 are as follows:

• 0 not applicable or unspecified
• 1 fetus 1
• 2 fetus 2
• 3 fetus 3
• 4 fetus 4
• 5 fetus 5
• 9 other fetus

The seventh character of "0" is assigned as follows:

• For single gestation
• When the documentation in the record is insufficient to determine the fetus affected and it is not possible to obtain clarification
• When it is not possible to clinically determine which fetus is affected

The following scenarios illustrate the assignment of the seventh character in Chapter 15 of ICD-10-CM.

Scenario 1

Premature delivery at 32 weeks; premature rupture of membranes, onset of labor five hours later; twin gestation; cord around neck without compression for both fetus one and fetus two; both fetuses are liveborn.

Codes:

• O60.14X0, Pre-term labor third trimester with pre-term delivery third trimester, not applicable or unspecified
• O42.013, Pre-term premature rupture of membranes, onset of labor within 24 hours of rupture, third trimester
• O69.81X1, Labor and delivery complicated by cord around neck, without compression, fetus 1
• O69.81X2, Labor and delivery complicated by cord around neck, without compression, fetus 2
• O30.003, Twin pregnancy, unable to determine number of placenta and number of amniotic sacs, third trimester
• Z37.2, Twins, both liveborn
• Z3A.32, 32 weeks gestation of pregnancy

For the premature labor and delivery code, a seventh character of "0" is assigned since the documentation does not specify which fetus is affected by the complication. Two codes are needed for the cord around neck without compression since the documentation indicates that both fetus one and fetus two were affected by the complication.

Scenario 2

Premature delivery at 33 weeks; face presentation; cord around neck without compression; single liveborn.

Codes:

• O60.14X0, Premature labor third trimester with pre-term delivery third trimester, not applicable or unspecified
• O32.3XX0, Maternal care for face, brow, and chin presentation, not applicable or unspecified
• O68.81X0, Labor and delivery complicated by cord around neck, without compression, not applicable or unspecified
• Z37.0, Single liveborn
• Z3A.33, 33 weeks gestation of pregnancy

Per the coding guideline for fetus identification, a seventh character of "0" is assigned for all three obstetric complications since this is a single gestation.

I.C.15.l Alcohol and Tobacco Use During Pregnancy, Childbirth and the Puerperium

The ICD-10-CM coding guideline for alcohol use states that codes from subcategory O99.31, Alcohol use complicating pregnancy, childbirth, and the puerperium, should be assigned for any pregnancy case when a mother uses alcohol during the pregnancy or postpartum. A secondary code from category F10, Alcohol related disorders, is also assigned to identify manifestations of the alcohol use.

Scenario 1

This scenario offers an example of how to code encounters following this guideline.

Pregnancy, delivered at 39 weeks of gestation; single liveborn; alcohol abuse.

Codes:

• O99.314, Alcohol use complicating childbirth
• F10.10, Alcohol abuse uncomplicated
• Z37.0, Single liveborn
• Z3A.39, 39 weeks gestation of pregnancy

The ICD-10-CM coding guideline for tobacco use states that codes from subcategory O99.33, Smoking (tobacco) complicating pregnancy, childbirth, and the puerperium, should be assigned for any pregnancy case when a mother uses any type of tobacco product during the pregnancy or postpartum. A secondary code from category F17, Nicotine dependence, should also be assigned to identify the type of nicotine dependence.

Scenario 2

This scenario offers an additional example of how to code encounters following this guideline.

Pregnancy, delivered at 39 weeks of gestation; single liveborn; tobacco dependence; patient smokes two packs of cigarettes daily.

Codes:

• O99.334, Smoking (tobacco) complicating childbirth
• F17210, Nicotine dependence, cigarettes, uncomplicated
• Z37.0, Single liveborn
• Z3A.39, 39 weeks gestation of pregnancy

References

National Center for Health Statistics. "ICD-10-CM Official Guidelines for Coding and Reporting 2014." http://www.cdc.gov/nchs/data/icd9/icd10cm_guidelines_2014.pdf.

National Center for Health Statistics. "International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM): 2013 release of ICD-10-CM." www.cdc.gov/nchs/icd/icd10cm.htm.

Ann Barta (ann.barta@ahima.org) is a director of HIM practice excellence at AHIMA.