It is the providers responsibility to state that the condition being treated is

It is the providers responsibility to state that the

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state, incidental, should be used in place of any chapter 15 codes. It is the provider’s responsibility to state that the condition being treated is not affecting the pregnancy. 2) Chapter 15 codes used only on the maternal record Chapter 15 codes are to be used only on the maternal record, never on the record of the newborn. 3) Final character for trimester The majority of codes in Chapter 15 have a final character indicating the trimester of pregnancy. The timeframes for the trimesters are indicated at the beginning of the chapter. If trimester is not a component of a code, it is because the condition always occurs in a specific trimester, or the concept of trimester of pregnancy is not applicable. Certain codes have characters for only certain trimesters because the condition does not occur in all trimesters, but it may occur in more than just one. Assignment of the final character for trimester should be based on the provider’s documentation of the trimester (or number of weeks) for the current admission/encounter. This applies to the assignment of trimester for pre-existing conditions as well as those that develop during or are due to the pregnancy. The provider’s documentation of the number of weeks may be used to assign the appropriate code identifying the trimester. Whenever 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. 4) Selection of trimester for inpatient admissions that encompass more than one trimester In instances when a patient is admitted to a hospital for complications of pregnancy during one trimester and remains in the hospital into a subsequent trimester, the trimester character for the antepartum complication code should be assigned on the basis of the trimester when the complication developed, not the trimester of the 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. 5) Unspecified trimester Each category that includes codes for trimester has a code for “unspecified trimester.” The “unspecified trimester” code should rarely be used, such as when the documentation in the record is insufficient to determine the trimester and it is not possible to obtain clarification. 6) 7th character for fetus identification Where applicable, a 7th 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 7th 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.
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