Ob-Gyn Coding Alert

2022 ICD-10-CM:

Focus on These Excludes1, Excludes2 Details and New Counseling, Polyuria Additions

You’ll find a new update to Z3A instructions, too.

In a year rife with coding changes, you can breathe a sigh of relief. The 2022 ICD-10-CM code set does not bring any substantial alterations to your day-to-day ob-gyn claims. However, don’t make the mistake of not staying vigilant. The following details can make or break a claim, so be sure you’re in the know by examining what’s new. These changes go into effect October 1, 2021.

Excludes1 Note Becomes Excludes2 for These Codes

Refresher: The ICD-10-CM guidelines offer the following instructions regarding an Excludes1 note:

  • “A type 1 Excludes note is a pure excludes note. It means ‘not coded here.’ An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.”

As you can see, these guidelines simply instruct you not to code any two given diagnoses at the same time. The classic conundrum that coders experience time and time again comes in their confusion about which code should they report versus which they should omit. Fortunately, the AHA Coding Clinic offers a definitive answer in their 2018 Q4 edition.

In the Coding Clinic Q&A, the reader asks for guidance in determining whether the main code listed in the tabular or the code referenced in the Excludes1 note should be reported. The Coding Clinic responds as follows:

  • “Assign only the code referenced in the Excludes1 note.”

This means that, assuming one of the two diagnosis codes has an Excludes1 note beneath it, you should code according to the Excludes1 note instructions.

This may be why ICD-10 2022 deletes the Excludes1 note underneath N97 (Female infertility), which states, “Excludes1: female infertility associated with hypopituitarism (E23.0), Stein-Leventhal syndrome (E28.2).”

Revision: Instead, you will see the same information shifts to an Excludes2 note. In your ICD-10 manual, you will see: “Excludes2: female infertility associated with hypopituitarism (E23.0), Stein-Leventhal syndrome (E28.2).”

Remember, an Excludes2 note means a specific condition is “not included here.” In other words, a condition identified by an Excludes2 note is medically related to the main condition but can occur independently of that condition. It is separately reportable under a different ICD-10 code and not included under the ICD-10 code under which the Excludes2 note appears.

Example: So, if your claim includes N97 as well as E23.0, you can report both diagnoses.

Similarly, underneath Z79.4 (Long term (current) use of insulin), you will shift the Excludes1 note including “long term (current) use of oral hypoglycemic drugs (Z79.84)” and “long term (current) use of oral antidiabetic drugs (Z79.84) to an Excludes2 note.

Also, underneath Z31 (Encounter for procreative management), you’ll currently see an Excludes1 note that includes “complications associated with artificial fertilization (N98-),” “female infertility (N97.-),” and “male infertility (N46.-).” This will also shift to an Excludes2 note, which means that if a patient sees your patient for procreative management and she has female infertility, you can report both Z31 and a code from the N97 series.

A Mere Comma Can Make a Big Difference

ICD-10 2022 added a comma to the “use additional codes” underneath two deep vein thrombosis diagnosis notes.

Currently, if you look under both O22.3 (Deep phlebothrombosis in pregnancy) and O87.1 (Deep phlebothrombosis in the puerperium), you will see use additional codes listed as “(I82.4-, I82.5-, I82.62-. I82.72-).” After the change they are “(I82.4-, I82.5-, I82.62-, I82.72-).” That is, the codes are separate, not one in a range from I82.62- to I82.72-.

Signs and Symptoms Section Gets New Polyuria Codes

Underneath “Symptoms and signs involving the genitourinary system (R30-R39),” you have some new codes, you will find a few polyuria changes.

Polyuria code R35 (Polyuria) remains the same, but you will delete R35.8 (Other polyuria). Instead, you’ll add new code R35.90 (Other polyuria), which has the note “Polyuria NOS” underneath it.

Additionally, you will add R35.81 (Nocturnal polyuria) with an Excludes2 note stating “Excludes2: nocturnal enuresis (N39.44).”

Plus, Check Our New Immunization Counseling Code

Thanks to a new code, you will have tweaks to Z23 (Encounter for immunization) and Z28 (Immunization not carried out and underimmunization status). Underneath both of these codes, you will have a notation that states, “Code also, if applicable, encounter for immunization safety counseling (Z71.85).”

This means that if a nervous patient comes in for an HPV vaccine and the ob-gyn spends time counseling her on the safety of this vaccine, you will report brand new code Z71.85 (Encounter for immunization safety counseling). This code includes notation underneath that state:

  • Encounter for vaccine product safety counseling Code also, if applicable, encounter for immunization (Z23)
  • Code also, if applicable, immunization not carried out (Z28.-)
  • Excludes1: encounter for health counseling related to travel (Z71.84)

Finally, New Update Clarifies Z3A Instructions

You’re used to applying Z3A- (Weeks of gestation) codes to describe the gestational weeks on the maternal record. But you’ll find clarifying instructions after October 1. Instead of the “Code first” note that says “complication of pregnancy, childbirth and the puerperium (O09-O9A),” you’ll see a “Code first” note that says “obstetric condition or encounter for delivery (O09-O60, O80-O82).”

“Basically, they have removed codes that apply to a post-delivery condition, which makes sense,” says Melanie Witt, RN, an independent coding expert based in Guadalupita, New Mexico. The reason why it does is because “Z3A only applies to antepartum through delivery time period (and also excludes abortive pregnancies, which were never included in the code first note).”