Diagnosis Guidelines and other ‘tips’ for Obstetrical Coding

5/16/2023

Diagnosis Guidelines and other `tips' for Obstetrical Coding

Copyright ? 2023 AAPC

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Disclaimer

? The information provided in this presentation is not a legal resource. While every attempt is made to provide accurate, current information, this information was obtained from third-party sources. Information is subject to change without notice. All attendees should be responsible for monitoring CMS updates and changes, as well as specific source guidance from individual payers. The contents of the presentation are to be used as guidelines.

? This information is also not all-inclusive, and not payer specific. OB is often an area with very specific payer needs, so payer policies, websites, and contracts must be reviewed

...one more thing......

Know your payers!

Some payers may have special payer instructions and may not follow the traditional CPT guidelines

Many Medicaid plans may want each individual visit reported separately

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Key Objectives

Understand the concepts and guidelines of OB diagnosis coding Recognize how to bill the global package for delivery Know what is and is not included in the global OB package Understand some common definitions and concepts

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Common Definitions and Concepts

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Copyright ? 2023 AAPC

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Common Definitions and General Rules

? Amenorrhea-absence of menstruation

? Unspecified N91.2 ? Primary N91.0

? Lack of any menstruation in a woman at least 16 years of age ? Secondary N91.1

? When established menstruation has ceased for 3 months in a woman with a history of regular cycles.

? Gravida-indicates number of times a patient has been pregnant

? Term indicates a woman who has been pregnant; including abortions, ectopic or molar pregnancies. Prima gravida is a woman's first pregnancy ? Elderly Primigravida ? This refers to a woman who will be 35 years of age of older at expected date of delivery. O09.5 ? Young ? A pregnancy that occurs in a female less than 16 years old at expected date of delivery. O09.6

? DO not use the O09.5 or the O09.6 at the time of the delivery; these should be captured only to show the HIGH risk status during the antepartum period

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Fetal Demise vs. Abortion vs. Stillbirth

? Intrauterine fetal demise indicates no fetal heartbeat detected after 20 weeks' gestation, while missed abortion refers to the event occurring prior to 20 weeks' gestation. (O36.4XX?)

? Intrauterine fetal death refers to babies with no signs of life in utero ? A `late' intrauterine death is when it happens in a woman who is 24 weeks pregnant or more, and is estimated to occur in 1% of all pregnancies

? Stillbirth: The Perinatal Mortality Surveillance Report (CEMACH)3 defined stillbirth as 'a baby delivered with no signs of life known to have died after 24 completed weeks of pregnancy'. (P95 captures the diagnosis for stillbirth and goes on the infant record)

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Abortion

? Missed (O02.1) ? Early fetal death before completion of 20 weeks, with retention of dead fetus or retained products of conception

? Incomplete (O03.4) ? Not all the products of conception are expelled at the time of encounter.

? Complete (O03.9) ? All of the products of conception are expelled at the time of encounter. Can include elective and therapeutic legal abortions.

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Abbreviations

? "G" followed but a number denotes the number of pregnancies. ? "P" followed by a number denotes the number of fetuses delivered over 500

grams. ? "AB" followed by a number denotes the number of abortions

In most all cases, if the patient is currently pregnancy the "G" number will be one greater than the total.

G4P2AB1, for instance, four pregnancies are counted but only 3 have been (2 deliveries and one abortion) the 4th pregnancy is current

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Stages of Labor and Pregnancy

? First is the onset of labor to complete dilation. ? Latent--dilation less than 4 cm and regular contractions ? Active--dilation greater than 4 cm

? Second when the cervix has complete dilation and the fetus begins to transition. ? Physicians who document "prolonged labor" need to back it up with documentation showing the time involved**

? Postpartum begins immediately after delivery and continues for 6 weeks. ? Peripartum is the last month of pregnancy to 5 weeks postpartum ? Postpartum Complication is any complication occurring with the 6-week period

following delivery.

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Weeks of gestation

? The period of gestation is the number of completed weeks of pregnancy, between the first day of the last menstrual period and the date in question. ? The Z3A Category is where you will find your weeks of gestation EXAMPLE 21 weeks gestation of pregnancy means up to 21 weeks 6 days and you would us Z3A.21 to capture your weeks of gestation

It does not switch to the next week until the full previous week is reached

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