Anthelio ICD-10 ExpressLearn ICD-10-PCS: Obstetrics

1 ICD-10 -PCS: Obstetrics 2015 Anthelio Healthcare Solutions Inc. Proprietary and confidential. All Rights ICD-10 ExpressLearnJuly 23, 2015 The ICD-10 -PCS Official Guidelines for Coding and Reporting 2015 for Obstetrics are brief, only consisting of two points:Products of conception C1 Procedures performed on the products of conception are coded to the Obstetrics section. Procedures performed on the pregnant female other than the products of conception are coded to the appropriate root operation in the Medical and Surgical section. Example: Amniocentesis is coded to the products of conception body part in the Obstetrics section.

2 Repair of obstetric urethral laceration is coded to the urethra body part in the Medical and Surgical section. Procedures following delivery or abortion C2 Procedures performed following a delivery or abortion for curettage of the endometrium or evacuation of retained products of conception are all coded in the Obstetrics section, to the root operation Extraction and the body part Products of Conception, Retained. Diagnostic or therapeutic dilation and curettage performed during times other than the postpartum or post-abortion period are all coded in the Medical and Surgical section, to the root operation Extraction and the body part is only one Body System (character 2): are three Body Part characters (character 4): 1.

3 Products of conception; 2. Products of conception, retained; 3. Products of conception, are currently only twelve Root Operations (character 3) in the Obstetrics Section, two of which only appear inthis section, Delivery and Abortion: 1. Change 2. Drainage 3. Abortion - Artificially terminating a pregnancy 4. Extraction 5. Delivery - Assisting the passage of the products of conception from the genital canal (only used for manually assisted vaginal deliveries) 6. Insertion 7. Inspection 8. Removal 9. Repair 10.

4 Reposition 11. Resection 12. TransplantationVol. 17 HALO ICD-10 ExpressLearn 2015 Anthelio Healthcare Solutions Inc. Proprietary and confidential. All Rights 1: 27 year old G2P1 at 39 weeks gestation presents in active labor. AROM is performed and spontaneous vaginal delivery over intact perineum occurs 2 hours does the coder know? Vaginal delivery 10E0 XZZ Intact perineum No Code AROM to augment labor 10907 ZCICD-10-PCS Index - Vaginal delivery ICD-10 -PCS TableICD-10-PCS Index - AROMICD-10-PCS TableJuly 23, 2015 Vol. 17109 Delivery Cesarean see Extraction, Products of Conception 10D0 Forceps see Extraction, Products of Conception 10D0 Manually assisted 10E0 XZZ Section 1 ObstetricsBody System 0 PregnancyOperation E Delivery: Assisting the passage of the products of conception from the genital canalSection 1 ObstetricsBody System 0 PregnancyOperation 9 Drainage.

5 Taking or letting out fluids and/or gases from a body part Body Part Approach Device Qualifier0 Products of Conception 0 Open 9 Fetal Blood 3 Percutaneous A Fetal Cerebrospinal Fluid 4 Percutaneous Endoscopic Z No Device B Fetal Fluid, Other 7 Via Natural or Artificial Opening C Amniotic Fluid, Therapeutic 8 Via Natural or Artificial Opening Endoscopic D Fluid.

6 Other U Amniotic Fluid, DiagnosticAROM (artificial rupture of membranes) 10907ZC 0 Products of Conception X External Z No Device No Qualifier10E Body Part Approach Device QualifierICD-10-PCS TableHALO ICD-10 ExpressLearn 2015 Anthelio Healthcare Solutions Inc. Proprietary and confidential. All Rights 23, 2015 Vol.

7 17 Repair Muscle Perineum 0 KQMS ection 0 Medical and SurgicalBody System K MusclesOperation Q Repair: Restoring, to the extent possible, a body part to its normal anatomic structure and functionD Hand Muscle, LeftF Trunk Muscle, RightG Trunk Muscle, LeftH Thorax Muscle, RightJ Thorax Muscle, LeftK Abdomen Muscle, RightL Abdomen Muscle, LeftM Perineum Muscle0 Open3 Percutaneous4 Percutaneous EndoscopicZ No DeviceZ No Qualifier Body Part Approach Device QualifierScenario 2: 24 year old G1P0 at 37 weeks gestation presents in active labor. A vaginal, vacuum assisted, delivery occurs 8 hours later.

8 A second degree perineal laceration is does the coder know? 1. A second degree perineal laceration is repaired 0 KQM0ZZ 2. A vacuum delivery 10D07Z6 What does the coder need to know? First: Sequencing of the procedures is based on both diagnostic and procedural Guidelines When a delivery occurs, the principal diagnosis should correspond to the main circumstances or complication of the delivery. 2nd degree laceration is the main complication in this case Sequence procedure performed for definitive treatment most related to principal diagnosis as principal procedure. Second: The anatomy involved in obstetrical lacerations.

9 1st degree - involves the skin and subcutaneous tissue of the perineum 2nd degree - involves the skin and subcutaneous tissue of the perineum, and pelvic floor muscles 3rd degree - involves the skin and subcutaneous tissue of the perineum, pelvic floor muscles, and the anal sphincter 4th degree - involves the skin and subcutaneous tissue of the perineum, pelvic floor muscles, the anal sphincter, and the rectal mucosa Third: The Guideline dealing with Overlapping body layers If the root operations Excision, Repair or Inspection are performed on overlapping layers of the musculoskeletal system, the body part specifying the deepest layer is Index - A second degree perineal laceration is repaired 0 KQHALO ICD-10 ExpressLearn 2015 Anthelio Healthcare Solutions Inc.

10 Proprietary and confidential. All Rights 23, 2015 Vol. 17 Delivery Manually assisted 10E0 XZZ Products of Conception 10E0 XZZ Vacuum assisted see Extraction, Products of Conception 10D0 Delivery Cesarean see Extraction, Products of Conception 10D0 Forceps see Extraction, Products of Conception 10D0 Section 1 ObstetricsBody System 0 PregnancyOperation D Extraction: Pulling or stripping out or off all or a portion of a body part by the use of force0 Products of Conception7 Via Natural or Artificial OpeningZ No Device3 Low Forceps4 Mid Forceps5 High Forceps6 Vacuum7 Internal Version8 Other Body Part Approach Device QualifierICD-10-PCS Index - A vacuum delivery Scenario 3: 27 year old G3P1A1 at 38 weeks gestation presents in active labor.