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Delivery dx code for uncomplicated delivery with high risk pregnancy

  1. #1
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    Unhappy Delivery dx code for uncomplicated delivery with high risk pregnancy
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    ICD 10 Code O80 shows Encounter for full-term uncomplicated delivery. There is a note that states: ...This code is for use as a single diagnosis code and is not to be used with any other code from chapter 15.

    I have an OP Note for a patient that was induced at 39 weeks. She had a diagnosis of Oligohydramnios and Small for gestational age fetus. The reason for induction is because her amniotic flud dropped to 4 and during an amniotomy there was no fluid noted. The delvery however went well, it was quick, no lacerations or problems of any kind. I cannot determine which code to use for the delivery. The Oligohydramnios O41.030 is third trimester, not delivery. The small for age fetus O36.5930 is the same situation, it is not a delivery code. The physician has also been adding O09.93 "Supervision of high risk pregnancy, unspecified, third trimester" to the office notes. How do I code a full term uncomplicated delivery with High Risk pregnancy?
    Rose Patterson, CPC, COC, COBGC

  2. #2
    Default Delivery dx code for uncomplicated delivery with high risk pregnancy
    Hi Rose,
    The official guidelines for coding and reporting in chapter 15 reads...Codes from category O09, Supervision of high-risk-pregnancy,are intended for use only during the prenatal period. For complications during the labor or delivery episode as a result of a high-risk-pregnancy, assign the applicable complication codes from Chapter 15. If there are no complications during the labor or delivery episode, assign code O80, Encounter for full-term uncomplicated delivery. I hope this helps.

    Donna

  3. #3
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    The guidelines also state:

    Chapter 15 B)Selection of OB Principal or First-listed Diagnosis

    4) When Delivery Occurs

    When an obstetric patient is admitted and delivers during that admission, the condition that prompted the admission should be sequenced as the principal diagnosis. If multiple conditions prompted the admission, sequence the one most related to the delivery as the principal diagnosis. A code for any complication of the delivery should be assigned as an additional diagnosis. In cases of cesarean delivery, if the patient was admitted with a condition that resulted in the performance of a cesarean procedure, that condition should be selected as the principal diagnosis. If the reason for the admission was unrelated to the condition resulting in the cesarean delivery, the condition related to the reason for the admission should be selected as the principal diagnosis.

    AHG
    CPC, CPMA

  4. #4
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    Additionally:

    Chapter 15 Official Guidelines

    N) Normal Delivery, Code O80

    1) Encounter for full term uncomplicated delivery Code 080 should be assigned when a woman is admitted for full-term normal delivery and delivers a single, healthy without any complications ANTEPARTUM, during the delivery or postpartum during the delivery episode. ... It is NOT to be used if any other code from chapter 15 is needed to describe a current complication of the antenatal, delivery or perinatal period.
    Last edited by ahguzman; 08-29-2018 at 11:59 AM.

  5. Default delivery dx code for uncomplicated delivery with high risk pregnancy
    The codes you will use for delivery will be: O41.03; O36.5930, Z37.0 and Z3A.39. The oligo and the IUGR prompted the induced labor/delivery so you would not use the normal delivery O80. The oligo and IUGR also would indicate high risk pregnancy. Just because nothing happened during the delivery("uncomplicated") does not mean it was not a high risk pregnancy.

    AHGuzman is correct.

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