OBSTETRICS and GYNECOLOGY

OBSTETRICS and GYNECOLOGY

INSTEAD OF

PLEASE CONSIDER ALSO INCLUDING:

ICD 10 Themes:

Acuity/Severity/Type/Staging

e.g. Acute on Chronic Systolic Heart Failure

Acute/Chronic/Acute on Chronic Mild, Moderate, Severe

Systolic, Diastolic, Combined

Stage I, II, III, IV

Anatomy/Site Specificity

e.g. Malignant neoplasm of lower lobe right bronchus

Location of tumor Bone/Joint/Muscle involved

e.g. Decubitus Ulcer, Stage 3, Right Buttocks,

Laterality

Present on Admission

Right/Left/Bilateral/Overlapping (see Neoplasm

re overlaps two or more contiguous (next to each

other) sites)

e.g. Hypertensive heart disease with chronic systolic Manifestations ? LINK IT!

heart failure

Associated or Related Conditions

`With'/`Secondary' to/'Due to'

`Evidence of' and causative organism

Use `no organism isolated', instead of

`negative culture'

e.g. Likely Sepsis secondary to UTI;

Etiology ? `DUE TO' WhAt?

Evidence of Bacterial Pneumonia (`Evidence of' in outpt setting can be captured as a diagnosis)

`LIKELY' suspects....Who dun it? Possible, Probable, Suspected (Inpt Only)

Evidence of, As Evidenced by (Outpt Setting and

Inpt Setting)

e.g. Drug Poisoning/Adverse Effect

Episode of Care/Incidence of Encounter

(Trauma/Fractures/Medication.Chemical Event(Drug

Poisoning))

Initial/Subsequent/Sequela

Time Frame:

Antepartum/Post Partum/Delivered (Changed to Trimester...okay for MD to put in Gestational Weeks, Coder will convert)

Trimester/Weeks of Gestation 1st = < 14 wks, 0 days 2nd = 14 wks, 0 days to 28 weeks, 0 days 3rd = 28 wks, 0 days until delivery)

ALWAYS INCLUDE ON EACH ENCOUNTER

Top Diagnosis Codes by Specialty:

Time Frame:

Late Pregnancy

Post Term is > 40 weeks ? 42 weeks; Prolonged is > 42 weeks

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Rev. 9.29.2015

Cesarean Section, Indication for Delivery with Laceration

Etiology: Repeat (Previous)/ Breech/ Cephalopelvic Disproportion (CPD); etc

Stage: 1st, 2nd, 3rd, 4th Degree Tear Anatomical Site: Perineal/Anal Sphincter Procedure: Description of how/what repaired

Obstructed Labor

Abnormal Fetal Heart Rate or Rhythm Advanced (Elderly) Maternal Age Delivery ( 35yrs) Breech Cord (Nuchal) Entanglement/Around Neck

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Etiology: Malposition or Malpresentation: Incomplete Rotation of Head/Breech, Face, Brow, Shoulder, or Compound Presentation/Other, i.e. Footling or Incomplete Breech Presentation Maternal Pelvic Abnormality, i.e.: Deformed Pelvis/Contracted Pelvis/Pelvic Inlet Contraction/Pelvic Outlet and Mid-Cavity Contraction/Fetal Pelvic Disproportion/Abnormality of pelvic organ, e.g. congenital malformation of uterus or cervical incompetence/Other Other Etiology: Shoulder Dystocia/Locked Twins/Unusually Large Fetus

Type: Bradycardia/Decelerations/Irregularity/Tachycardia etc

Time Frame: Trimester/Weeks of Gestation Type: Primigravida/Multigravida

Type: Complete; Incomplete (Footling); Frank

Etiology: Around Neck, With or Without Compression Entanglement, With or Without Compression Other Etiologies: Prolapse of Cord/Short Cord/Vasa Previa/Vascular lesion of cord/Other

Rev. 9.29.2015

Postpartum Hemorrhage Delayed Delivery after ROM

Primary Uterine Inertia Prolonged Second Stage of Labor Precipitate Labor

Type: Third Stage (associated with retained placenta); Other Immediate (following delivery of placenta or uterine atony); Delayed and Secondary (retained portions of placenta after 1st 24 hours of delivery)

Type: Spontaneous/Artificial or Other (Coded as Premature ROM) Time Frame: With Onset of Labor

after or within 24 hours Trimester/Weeks of Gestation: Full Term (after 37 completed Weeks of Gestation) Pre ? Term (before 37 completed Weeks of Gestation)

Type: Primary (Failure of Cervical Dilation) /Secondary (Arrested Active Phase of Labor) Time Frame: Trimester/Weeks of Gestation

Stage: First Stage/ Second Stage/ Delayed Delivery of second twin, etc. Time Frame: Trimester/Weeks of Gestation

Time Frame: Trimester/Weeks of Gestation

Abnormal Glucose Tolerance

Etiology: Diabetes Mellitus/Hypoglycemia/Antenatal Screening/Complicating Pregnancy/Glycosuria/Other

Time Frame: Trimester/Weeks of Gestation

Early Onset Delivery

Time Frame: Trimester/Weeks of Gestation

Onset of Delivery after 37 weeks, planned C Section

Time Frame: Trimester/Weeks of Gestation

Etiology: Breech/Distress/Cephalopelvic disproportion/Failed (e.g. forceps)/Malposition/Hemorrhage (intrapartum)/Planned, Other

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Pre-eclampsia

Severity: Mild-Moderate or Severe

Indicate if with HELLP Syndrome

Time Frame: Trimester/Weeks of Gestation

Abortion, Spontaneous

Type: Spontaneous/Induced

Manifestation: Complete/Incomplete

Complications: Genital tract and pelvic infection/Delayed or excessive hemorrhage/Embolism/Shock/Renal Failure/Metabolic Disorder/Damage to Pelvic Organs/Other Venous/Cardiac Arrest/Sepsis/UTI/Other/

Hyperemesis (Note: Coders canNOT code `' `', must state the imbalance i.e. hyponatremia)

Re: Hyperemesis Gravidarum - definition of early vs. late pregnancy changed to 20 weeks (from 22 weeks)

Manifestations: With dehydration/electrolyte imbalance/Severe (with metabolic disturbances)

Specify the metabolic disturbance, i.e. Acute Renal Failure, Hypovolemia

Specify the electrolyte imbalance i.e. Hyponatremia/Hypokalemia etc

Severity: Mild/Severe

Anemia (Acute Blood Loss Anemia does not reflect a complication of surgery, unless surgeon states it's a complication and there is a cause and effect relationship; May state `expected'/'inherent'; Documentation of `Post-op Anemia' is not enough, instead `Post Operative Anemia due to Acute Blood Loss')

Acuity: Acute/Chronic Etiology: Blood Loss; Iron Deficiency; Chemotherapy; Neoplastic; Aplastic, etc

Incidental to Pregnant State vs. Impacting Pregnancy

State "Does not affect or complicate the pregnancy" if incidental, otherwise will code as `impacting the pregnancy' e.g. Pregnant patient with burn of hand, "Burn of hand does not affect or complicate the pregnancy"

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Gestational Hypertension vs. Gestational Edema and Proteinuria without Hypertension (Findings of edema and proteinuria explain an increase in number of office visits and complexity of patient you are treating.)

Type: Gestational Edema and Proteinuria With Gestational Hypertension Without Gestational Hypertension

Pre-Existing vs. Pregnancy Induced Conditions

State `pre existing' vs. `pregnancy induced' i.e. Gestational Hypertension

Abnormal Findings on Antenatal Screening of Mother

Type: Hematological/Biochemical/Cytological/Ultrasonic/Radi ological/Chromosomal and Genetic/Other/Unspecified

Multiple Gestation - # placenta/# amniotic sacs

(Clarify which fetus related to problem, as applicable, Fetus 1 or Fetus 2)

For Twins: -Monochorionic/Monoamniotic -Monochorionic/Diamniotic -Dichorionic/Diamniotic, or -Unable to determine number of placenta and

number of amniotic sacs

Early Pregnancy

Time Frame: Changed to 20 weeks (from 22 weeks) Emphasized with: Hyperemesis Gravidarum/Abortions/Fetal Deaths/Hemorrhage

Pre-term Labor

Time Frame: Prior to 37 weeks

Uterine Leiomyoma (Fibroid Tumor)

Anatomical Site: Submucousal/Intramural/Subserosal/Unspecified

Dysmenorrhea

Type: Primary/Secondary/Psychogenic/Other

Diabetes

Terms i.e. `uncontrolled' or `inadequately controlled' code to `hyperglycemia'...even if recent `hypoglycemia'.....specifically use Hypoglycemia or Hyperglycemia instead. Or if used, stipulate if not hyperglycemic.

(be clear in note if patient has only an abnormal

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Type: Type 1 or Type 2 ; Drug or Chemical Induced; or Gestational Control Status (Insulin):

With: Hypoglycemia/Hyperglycemia

Insulin Use Associated Diagnosis/Conditions: i.e. ulcers Manifestations or Secondary related problems

Rev. 9.29.2015

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