ICD-10 for OB/GYN - Centers for Medicare & Medicaid …

1 1 ICD-10 Clinical Concepts SeriesICD-10 Clinical Concepts for OB/GYN is a feature of Road to 10, a CMS online tool built with physician input. ICD-10 With Road to 10, you can: l Build an ICD-10 action plan customized for your practice l Use interactive case studies to see how your coding selections compare with your peers coding l Access quick references from CMS and medical and trade associations l View in-depth webcasts for and by medical professionalsTo get on the Road to 10 and find out more about ICD-10 , visit: CMS Industry Resources for the ICD-10 Compliance Date: October 1, 2015 Clinical Conceptsfor OB/GYNC ommon CodesClinical Documentation TipsClinical Scenarios Scenario 1: Abdominal Pain & Ovarian cyst Scenario 2: Breast Lump/Annual Well Woman Exam Scenario 3: Preeclampsia Scenario 4.

2 Bacterial Vaginosis Clinical ScenariosTable Of ContentsCommon CodesPrimer for Clinical Documentation Abnormal Female Genital Cytology (Excluding Neoplasia and Malignancy Codes) Excessive, Frequent and Irregular Menstruation General Medical and Gynecological Examinations Hypertension Inflammation of Vagina and Vulva Lump in Breast and Other Disorders of Breast Selected Menopausal and other Perimenopausal Disorders Noninflammatory Disorders of Ovary, Fallopian Tubes and Broad Ligament Supervision of Normal Pregnancy Urinary Tract Infection, Cystitis Trimester Vomiting Abortion Childbirth and Puerperium Distinct from Trimester Intent of Encounter Complications of Pregnancy Alcohol Use, Substance Abuse and Tobacco Dependence3 Common CodesICD-10 Compliance Date.

3 October 1, Atypical squamous cells of undetermined significance on cytologic smear of cervix (ASC-US) Atypical squamous cells cannot exclude high grade squamous intraepithe- lial lesion on cytologic smear of cervix (ASC-H) Low grade squamous intraepithelial lesion on cytologic smear of cervix (LGSIL) High grade squamous intraepithelial lesion on cytologic smear of cervix (HGSIL) Unsatisfactory cytologic smear of Satisfactory cervical smear but lacking transformation Other abnormal cytological findings on specimens from cervix * Unspecified abnormal cytological findings in specimens from cervix Atypical squamous cells of undetermined significance on cytologic smear of vagina (ASC-US) Atypical squamous cells cannot exclude high grade squamous intraepithe- lial lesion on cytologic smear of vagina (ASC-H) Low grade squamous intraepithelial lesion on cytologic smear of vagina (LGSIL) High grade squamous intraepithelial lesion on cytologic smear of vagina (HGSIL) Unsatisfactory cytologic smear of Other abnormal cytological findings on specimens from * Unspecified abnormal cytological findings in specimens from Abnormal cytological findings in specimens from other female genital Mild cervical Moderate cervical * Dysplasia of cervix uteri, Cervical high risk human papillomavirus (HPV) DNA test Vaginal high risk human papillomavirus (HPV)

4 DNA test Cervical low risk human papillomavirus (HPV) DNA test Vaginal low risk human papillomavirus (HPV) DNA test positiveAbnormal Female Genital Cytology (Excluding Neoplasia and Malignancy Codes) (ICD-9-CM , , , , to range, )*Codes with a greater degree of specificity should be considered Encounter for general adult medical exam without abnormal Encounter for general adult medical exam with abnormal Encounter for gynecological examination (general) (routine) with abnormal Encounter for gynecological examination (general) (routine) without abnormal Encounter for cervical smear to confirm findings of recent normal smear fol lowing initial abnormal smearGeneral Medical and Gynecological Examinations (ICD-9-CM , , ) (Excluding Contraceptive and Procreative Codes)*Codes with a greater degree of specificity should be considered Excessive and frequent menstruation with regular Excessive and frequent menstruation with irregular Excessive menstruation at Ovulation Excessive bleeding in the premenopausal Other specified irregular * Irregular menstruation, unspecifiedExcessive, Frequent and Irregular Menstruation (ICD-9-CM To Range, )

5 *Codes with a greater degree of specificity should be considered Essential (primary) hypertensionHypertension (ICD-9-CM )*Codes with a greater degree of specificity should be considered Acute Subacute and chronic Acute Subacute and chronic Abscess of Ulceration of Ulceration of Mucositis (ulcerative) of vagina and Other specified inflammation of vagina and vulva N63* Unspecified lump in Fissure and fistula of Fat necrosis of Atrophy of Galactorrhea not associated with Induration of Nipple Retraction of Other signs and symptoms in Ptosis of Hypoplasia of Other specified disorders of * Disorder of breast, unspecifiedInflammation of Vagina and Vulva (ICD-9-CM , , , , )Lump in Breast and Other Disorders of the Breast (ICD-9-CM , , , , , to range, To range, )*Codes with a greater degree of specificity should be considered first.

6 *Codes with a greater degree of specificity should be considered Excessive bleeding in the premenopausal Postmenopausal Menopausal and female climacteric Postmenopausal atrophic Other specified menopausal and perimenopausal * Unspecified menopausal and perimenopausal disorderSelected Menopausal and Other Perimenopausal Disorders (ICD-9-CM to range) (Excluding Post-menopausal Osteoporosis and Urethritis Codes)*Codes with a greater degree of specificity should be considered Follicular cyst of Corpus luteum * Unspecified ovarian Other ovarian Acquired atrophy of Acquired atrophy of fallopian Acquired atrophy of ovary and fallopian Prolapse and hernia of ovary and fallopian Torsion of ovary and ovarian Torsion of fallopian Torsion of ovary, ovarian pedicle and fallopian Hematoma of broad Other noninflammatory disorders of ovary, fallopian tube & broad * Noninflammatory disorder of ovary, fallopian tube and broad ligament, unspecifiedNoninflammatory Disorders of Ovary, Fallopian Tubes, and Broad-ligament (ICD-9-CM to range)

7 *Codes with a greater degree of specificity should be considered * Encounter for supervision of normal first pregnancy, unspecified Encounter for supervision of normal first pregnancy, first Encounter for supervision of normal first pregnancy, second Encounter for supervision of normal first pregnancy, third * Encounter for supervision of other normal pregnancy, unspecified Encounter for supervision of other normal pregnancy, first Encounter for supervision of other normal pregnancy, second Encounter for supervision of other normal pregnancy, third * Encounter for supervision of normal pregnancy, unspecified, unspecified * Encounter for supervision of normal pregnancy, unspecified, first * Encounter for supervision of normal pregnancy, unspecified, second * Encounter for supervision of normal pregnancy, unspecified, third trimesterSupervision of Normal Pregnancy (ICD-9-CM , , )*Codes with a greater degree of specificity should be considered Acute cystitis without Acute cystitis with Interstitial cystitis (chronic) without Interstitial cystitis (chronic)

8 With Other chronic cystitis without Other chronic cystitis with Trigonitis without Trigonitis with Irradiation cystitis without Irradiation cystitis with Other cystitis without Other cystitis with Cystitis, unspecified without Cystitis, unspecified with * Urinary tract infection, site not specifiedUrinary Tract Infection, Cystitis (ICD-9-CM , , , , , , , , , )*Codes with a greater degree of specificity should be considered anatomical location and laterality required by ICD-10 is easier than you think. This detail reflects how physicians and clinicians communicate and to what they pay attention - it is a matter of ensuring the information is captured in your documentation. In ICD-10 -CM, there are three main categories of changes: Definition Changes Definition Change Increased SpecificityOver 1/3 of the expansion of ICD-10 codes is due to the addition of laterality (left, right, bilateral).

9 Physicians and other clinicians likely already note the side when evaluating the clinically pertinent anatomical site(s).TRIMESTERD efinition Change Documentation of trimester is required. Determination is calculated from first day of last menstrual period, and is documented in definitions of trimesters are: 1. First Trimester Less than 14 weeks, 0 days2. Second Trimester 14 weeks, 0 days through 27 weeks and 6 days3. Third Trimester 28 weeks through deliveryClinical Documentation TipsICD-10 Compliance Date: October 1, Spotting complicating pregnancy, first Spotting complicating pregnancy, second Spotting complicating pregnancy, third Spotting complicating pregnancy, unspecified trimesterICD-10 Code Examples9 VOMITINGD efinition Change The time frame for differentiating early and late vomiting in pregnancy has been changed from 22 to 20 ChangeThe timeframe for a missed abortion (vs.)

10 Fetal death) has changed from 22 to 20 weeks. In ICD-10 -CM, an elective abortion is now described as an elective termination of are four spontaneous abortion definitions in ICD-10 ; use the appropriate definition in your documentation: Abortion No bleeding, os closed 2. Threatened Abortion Bleeding, os closed 3. Incomplete Abortion Bleeding, os open, products of conception (POC) are extruding 4. Complete Abortion Possible bleeding or spotting, os closed, all POC Mild hyperemesis Late vomiting of pregnancyICD-10 Code Missed Maternal care for intrauterine death, fetus Encounter for elective termination of pregnancyICD-10 Code Examples10 CHILDBIRTH AND PUERPERIUM DISTINCT FROM TRIMESTERT erminology Difference ICD-10 allows for the description of pregnancy , childbirth and puerperium as distinct concepts from trimester.