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ICD-10 Coding Session OB/GYN/Midwifery

ICD-10 Coding Session OB/GYN/Midwifery. Susan Fisher, CNM, MSN Director, Athens Regional Nurse-Midwifery Practice Victoria A. Weinert, RHIT, CCS Audit and Compliance Manager, On Assignment. Case 1.

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ICD-10 Coding Session OB/GYN/Midwifery

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  1. ICD-10 Coding SessionOB/GYN/Midwifery Susan Fisher, CNM, MSN Director, Athens Regional Nurse-Midwifery Practice Victoria A. Weinert, RHIT, CCSAudit and Compliance Manager, On Assignment

  2. Case 1 Ms. Smith is a 40-year-old female, who presents for permanent sterilization. She has been seen by Dr. Jones and referred here. She has severe pulmonary fibrosis. This is the result of a severe MVA at age 13. She underwent pneumonectomy at that time and spent months at Egleston recovering. She has a splenectomy and lower lobe pneumonectomy. During this time she also had a pacemaker placed. She has no children and she understands that she should not have them with her medical conditions. She has tried other birth control methods and had various side effects which made continued use unfeasible. She desires permanent sterilization.

  3. Case 1 Past medical history: As above, severe MVA in 1986 with resultant pulmonary fibrosis. She also has migraine headaches. Past surgical history: As above, in addition cholecystectomy in 2008. Medications: Oxygen (24 hrs per day), Levaquin, Lasix Physical exam: Blood pressure 130/82, wt 201lbs, She has had a recent normal pap smear. Heart regular rate and rhythm. Lungs: Decreased breath sounds. The uterus is normal, cervix is nulliparous. Impression: Desire for permanent sterilization Severe Pulmonary fibrosis Obesity Hypertension Plan: Will proceed with an Essure sterilization procedure under local anesthesia with sedation.

  4. Essure Sterilization 1. Placing the Essure inserts Your doctor will place a soft and flexible insert into each of your fallopian tubes. No incisions are needed because the inserts are placed through the natural pathway of your vagina and cervix. 2. Formation of the natural barrier Over the next 3 months, your body forms a natural barrier around the Essure inserts that prevent sperm from reaching your eggs. During the 3-month period, you must continue using another form of birth control. 3. Essure Confirmation Test After 3 months, a doctor administers the Essure Confirmation Test using contrast dye and a special type of x-ray. The test confirms that the inserts are placed correctly, your fallopian tubes are blocked, and pregnancy is permanently prevented. Until you receive confirmation from your doctor, you must continue to use another form of birth control to prevent pregnancy. http://www.essure.com/how-essure-works/the-essure-procedure

  5. Coding Case 1 What are the Diagnoses/Procedures?

  6. Diagnoses Case 1 • Elective sterilization • Pulmonary Fibrosis • Obesity • Hypertension • History of Trauma to the Lung • Absence of Lung • Absence of spleen • Supplemental Oxygen • Insertion Essure device Procedures Case 1

  7. Case 2 Ms. Jones is a 23-yr-old G3P2 at 36 wks and 5 days gestation who presents to the OB emergency department with leaking amniotic fluid and irregular contractions. She has a history of two previous preterm deliveries. In 2010 she had a normal spontaneous vaginal delivery of a stillborn male infant at 32 wks gestation. In 2012 she delivered a 3lb female infant at 34 wks gestation by cesarean section for severe IUGR. She has been followed closely this pregnancy, and the estimated fetal weight of this infant is appropriate for gestational age. She has gestational diabetes which is diet controlled. Past Medical History: as above. Past Surgical History: Cesarean section with low transverse scar in 2012.

  8. Case 2 Impression: PPROM @ 36 wks 5 days Premature Delivery History of IUGR and stillbirth, currently pregnant Gestational Diabetes Obesity (BMI 36) Desires VBAC GBS positive Plan: Patient was admitted for trial of labor. Outcome: Pt subsequently had a normal, unmedicatedspontaneous vaginal delivery of a 5lb 6oz infant following 14 hours of labor. She had a first degree perineal laceration and an estimated blood loss of 300ml.

  9. Coding Case 2 What are the diagnoses/procedures?

  10. Diagnoses Case 2 • PPROM/Premature Delivery • Previous C-section • Previous preterm deliveries • Previous stillbirth • Gestational diabetes, diet controlled • Obesity, BMI 36 • GBS positive • Weeks of gestation • Outcome of Delivery • Manually assisted vaginal delivery Procedures Case 2

  11. Case 3 Ms. Garcia is a G2P0 with one previous miscarriage in the first trimester. Her first prenatal care visit was initiated at 26 wks and she had a total of five prenatal visits. The infant was found to have cleft lip/palate on a 26 wk anatomy scan. She presents to OB Emergency Depttoday @ 39 wks gestation. She is 7 cm dilated with intact amniotic membranes. She requests epidural anesthesia. Her blood type is O- and she is GBS negative. Past medical/surgical history: 8 wk incomplete miscarriage with D&C in 2011.

  12. Case 3 Impression: G2P0 in active labor Late/Inadequate prenatal care Fetus with cleft lip/palate Plan: Admit for labor, notify NICU to be present at delivery. Outcome: Seven hours after admission, Ms. Garcia had a vacuum assisted vaginal delivery of an 8lb 2oz infant. The infant was vigorous at birth and was attended to by the NICU team. Ms. Garcia had a fourth degree perineal laceration which was repaired by the attending MD. She had a postpartum hemorrhage with estimated blood loss of 600ml. The bleeding responded to pitocin and cytotec and her vital signs remained stable.

  13. ICD-10-PCS Official Guidelines for Coding and Reporting B. Medical and Surgical Section Guidelines (section 0) B3. Root Operation Overlapping body layers B3.5 If the root operations Excision, Repair or Inspection are performed on overlapping layers of the musculoskeletal system, the body part specifying the deepest layer is coded. Example: Excisional debridement that includes skin and subcutaneous tissue and muscle is coded to the muscle body part.

  14. Obstetrical Perineal Lacerations Taken from ICD-10- CM and ICD-10-PCS Coding Handbook 2014, p. 336

  15. Coding Case 3 What are the diagnoses/ procedures?

  16. Diagnoses Case 3 • Previous miscarriage • Inadequate prenatal care • Fetal Anomaly-cleft lip/palate • Fourth degree perineal laceration • Postpartum hemorrhage • Weeks of gestation • Outcome of delivery • Vacuum Assisted Vaginal Delivery • Repair 4th degree perineal laceration • Infusion, pitocin/cytotec Procedures Case 3

  17. Case 4 A 46 yr old woman presented to the ER for menorrhagia, which required a transfusion of 4 units of blood. Her medical history is significant for morbid obesity (BMI 76) and cardiomyopathy. Past Medical History: As above. No current medications. Past Surgical History: None Impression: 1) Menorrhagia 2) Morbid Obesity 3) Cardiomyopathy Plan: Pt needs a D&C, consult Cardiology for clearance. Outcome: The patient was cleared for a D&C. However, an endometrial biopsy was scheduled first and was performed in our office today. The pathology report came back and showed well differentiated/FIGO Grade 1 endometrioid type adenocarcinoma with associated complex hyperplasia with atypia, and extensive morular metaplasia.

  18. Coding Case 4 What are the diagnoses/procedures?

  19. Diagnoses Case 4 • Endometrial Adenocarcinoma • Menorrhagia • Morbid Obesity, BMI 76 • Cardiomyopathy • Endometrial Biopsy Procedures Case 4

  20. Case 5 A 31 yr old G1P0 was admitted to Labor and Delivery for induction at 37/1 wks for mild preeclampsia. She has a twin gestation with dichorionic, diamniotic twins. Twin A is in vertex position and twin B is breech. She was also recently diagnosed with intrahepatic cholestasis of pregnancy. She has mild anemia. She desires a trial of labor and understands that internal version of twin B may be necessary or that cesarean section may be necessary. Past Medical History: Unremarkable Past Surgical History: None Plan: Induction of labor.

  21. Case 5 Impression: IUP at 37/1 wks Twin Gestation Vertex/Breech Preeclampsia Intrahepatic Cholestasis of Pregnancy Anemia Outcome: On admission, Cervidil vaginal suppository was placed followed by intravenous Pitocin. After 14 hours of labor, twin A was delivered spontaneously without complications. Twin B was internally verted and delivered one hour later without complications. Pt had a seizure immediately following the birth of twin B. She was given Ativan and started on intravenous magnesium sulfate. She had a postpartum hemorrhage.

  22. Query Please assist with clarification of the diagnosis of anemia. On admission hgb was _, hct was _. Delivery was complicated by postpartum hemorrhage. After delivery, hgb was _, hct was _. Can you further specify the type of anemia treated during this admission? _X_Hemorrhagic Anemia __Acute Posthemorrhagic Anemia __Other (please specify) “The mild anemia was present antenatally and then worsened with the postpartum hemorrhage without need for transfusions.”

  23. Coding Case 5 What are the diagnoses/procedures?

  24. Diagnoses Case 5 • Mild pre-eclampsia • Postpartum hemorrhage • Twin gestation, di/di • Breech, fetus 2 • Anemia • Intrahepatic cholestasis of pregnancy • Weeks of gestation • Outcome of delivery • Manually assisted vaginal delivery • Medical induction of labor • Version of Twin B • Infusion magnesium sulfate Procedures Case 5

  25. How would you code the baby’s records? • Birth • Vaccinations? • Hearing Test? • Circumcision?

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