CHAPTER 12

1. CHAPTER 12 CHAPTER-SPECIFIC GUIDELINES (ICD-10-CM CHAPTERS 15-21)

2. Pregnancy, Childbirth, and the Puerperium, Chapter 15 • O00-O99 • Any condition that occurs during pregnancy, childbirth, or puerperium is a complication • Unless physician documents it neither: • Affects the pregnancy • Is affected by the pregnancy

3. Sequencing Priority • Chapter 15 codes have sequencing priority of codes from other chapters • Z33.1, incidental pregnancy state, is reported if the physician documents incidental status • Chapter 15 codes are only for mother’s record • Never newborn’s record

4. Routine Prenatal Visits • Routine outpatient prenatal visits with no complications = Z34 category code • First listed • Routine high-risk prenatal visits = O09 category code • First listed

5. Outcome of Delivery • Outcome of delivery • Z37 category code • Only reported once • On mother’s record

6. Trimester and Time Periods • Majority of codes, final character indicates trimester • Trimester calculated from last menstrual period (LMP) • First trimester: less than 14 weeks 0 days • Second trimester: 14 weeks 0 days to less than 28 weeks 0 days • Third trimester: 28 weeks 0 days until delivery • Peripartum = last month of pregnancy to 5 months postpartum • Postpartum = immediately after delivery to 6 weeks after delivery

7. Ectopic Pregnancy • Fertilized ovum implants outside the uterus • Reported with category O00, based on: • Location of pregnancy • Such as: ovarian or tubal • Complications associated with ectopic pregnancy: • Report category O08 code

8. Hydatidiform Mole • Tumor of the placenta • Secretes hormones • Report with category O01 • Report complication with category O08 • Malignant, report D39.2

9. Hypertension in Pregnancy • Pre-existing hypertension that complicates the pregnancy, delivery, or the five-month period after birth, Category O10 • First-listed code

10. Fetal Conditions • Category O35 and O36 report fetal abnormalities that affect the care of mother • If fetal abnormality does not affect care of mother, do not report O35 or O36

11. Diabetes Mellitus in Pregnancy • Type 1 = little or no insulin is produced • Controlled with insulin • Report long-term use of insulin • Type 2 = too little or the body cannot use the insulin that is produced • Controlled with diet, medications, and/or insulin • May report long-term use of insulin • Gestational diabetes develops in 2nd or 3rd trimester in patient who did not have diabetes prior to pregnancy • Do not report long-term use of insulin

12. Certain Conditions Originating in the Perinatal Period, Chapter 16 • P00-P96 • Chapter 16 codes only on newborn’s record • Z38 reports liveborn according to place of birth and type of delivery • First listed • Does not report congenital malformation, deformities, or abnormalities • Rather report with Q00-Q99

13. Congenital Malformations, Deformation, and Chromosomal Abnormalities, Chapter 17 • Q00-Q99 • May be a first-listed or secondary diagnosis • Sequence as secondary diagnosis with category Z38 code • Reported whenever condition is diagnosed • Congenital = born with • Physician must document abnormality

14. Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, NEC, Chapter 18 • R00-R99 • Sign = objective evidence of disease • Symptom = subjective observation • Report symptoms only when no more definitive diagnosis is available • Example: Pt complains of pain right lower quadrant. Diagnosis states acute appendicitis. • Do not report symptom of pain

15. Injury, Poisoning, and Certain Other Consequences of External Causes, Chapter 19 • S00-T88 • Many codes have 7th characters • A initial encounter • Receiving active treatment for the injury • D subsequent encounter • Completed active treatment and is receiving routine care during healing • S sequela • Direct result of injury, add S to injury code, not to sequela code

16. Traumatic Fractures • Fractures not indicated as • Open or closed, report as closed • Displaced or not displaced, report as displaced • Assign 7th character • A initial encounter for closed fracture • B initial encounter for open fracture • D subsequent encounter for fracture with routine healing • G subsequent encounter for fracture with delayed healing • K subsequent encounter for fracture with nonunion • S sequela (Cont’d…)

17. Traumatic Fractures (…Cont’d) • Multiple fractures, sequence according to severity • If dislocation and fracture of same bone, report only fracture • Category M80 reports non-traumatic fracture for patients with osteoporosis • Even if injury by trauma • Pathological fracture occurs due to disease or weakness

18. Burns and Corrosions • Thermal burns from heat source • Except sunburn • Corrosion burns due to chemicals • Guidelines same for burns and corrosions • Burns classified by depth: • 1st erythema • 2nd blistering • 3rd full-thickness (Cont’d…)

19. Burns and Corrosions (…Cont’d) • Sequence first • Highest degree of burn >1% • Multiple burns, same area • Report only the highest degree burn • Infected burns • Use additional code for infection • Late effects of burns • Report with burn or corrosion code + 7th character “S”

20. Adverse Effects, Poisoning, Underdosing, and Toxic Effects • T36-T65 • Combination codes that include • Substance • External cause • Sequence these codes 1st • Follow with code(s) that specify nature

21. Poisoning • Assign code from categories T36-T50, poisoning codes • Report any associated intent • Such as, accidental, intentional, etc. • Report all manifestations of poisoning • Such as, vomiting

22. Drug Adverse Effect or Poisoning • Adverse Effect: Occurs when drug is taken correctly but patient has negative response • Poisoning: Occurs when drug is incorrectly taken

23. Abuse, Neglect, or Maltreatment • Sequence first (T74.- or T76.-) • Medical documentation states • Abuse or neglect, code as confirmed • Suspected, code as suspected • Confirmed cases of abuse or neglect • Report an assault code (X92-Y08) to indicate physical injury • Report perpetrator code (Y07)

24. ConclusionCHAPTER 12 CHAPTER-SPECIFIC GUIDELINES (ICD-10-CM CHAPTER 15-21)