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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Rev. 9.29.2015
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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Rev. 9.29.2015
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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