6) 7 th character for Fetus Identification Where applicable, a 7 th character is to be assigned for certain categories (O31, O32, O33.3 - O33.6, O35, O36, O40, O41, O60.1, O60.2, O64, and O69) to identify the fetus for which the complication code applies. Assign 7 th character “0”: • For single gestations • 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.
ICD-10-CM Official Guidelines for Coding and Reporting FY 2017 Page 56 of 114 b. Selection of OB Principal or First-listed Diagnosis 1) Routine outpatient prenatal visits For routine outpatient prenatal visits when no complications are present, a code from category Z34, Encounter for supervision of normal pregnancy, should be used as the first-listed diagnosis. These codes should not be used in conjunction with chapter 15 codes. 2) Supervision of High-Risk Pregnancy Codes from category O09, Supervision of high-risk pregnancy, are intended for use only during the prenatal period. For complications during the labor or delivery episode as a result of a high-risk pregnancy, assign the applicable complication codes from Chapter 15. If there are no complications during the labor or delivery episode, assign code O80, Encounter for full-term uncomplicated delivery. For routine prenatal outpatient visits for patients with high-risk pregnancies, a code from category O09, Supervision of high-risk pregnancy, should be used as the first-listed diagnosis. Secondary chapter 15 codes may be used in conjunction with these codes if appropriate. 3) Episodes when no delivery occurs In episodes when no delivery occurs, the principal diagnosis should correspond to the principal complication of the pregnancy which necessitated the encounter. Should more than one complication exist, all of which are treated or monitored, any of the complications codes may be sequenced first. 4) When a delivery occurs When an obstetric patient is admitted and delivers during that admission, the condition that prompted the admission should be sequenced as the principal diagnosis. If multiple conditions prompted the admission, sequence the one most related to the delivery as the principal diagnosis. A code for any complication of the delivery should be assigned as an additional diagnosis. In cases of cesarean delivery, if the patient was admitted with a condition that resulted in the performance of a cesarean procedure, that condition should be selected as the principal diagnosis. If the reason for the admission was unrelated to the condition resulting in the cesarean delivery , the condition related to the reason for the admission should be selected as the principal diagnosis.
ICD-10-CM Official Guidelines for Coding and Reporting FY 2017 Page 57 of 114 5) Outcome of delivery A code from category Z37, Outcome of delivery, should be included on every maternal record when a delivery has occurred. These codes are not to be used on subsequent records or on the newborn record.
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- Summer '16
- Jennifer Lane
- DNA, Diagnosis codes, Braille, Major Diagnostic Category