Pregnancy codes have increased significantly in number in ICD 10. ICD 10, having lot of differences with the old ICD 9 codes, should be used very carefully. The only thing we have to do is to avoid few common mistakes with ICD 10 codes. Medical coders know that with the implementation of ICD 10 codes, they should be perfect with coding guidelines. Since, ICD 10 codes are very specific, we should try to avoid using other specified or unspecified codes. We have already learnt about when to use normal and incidental pregnancy ICD codes, but here we will learn when to use normal and pregnancy complication ICD 10 codes.
IC10 code for Normal Delivery
There are specific ICD 10 codes for normal and cesarean delivery. However, most of us always have confusion when to use normal delivery codes. You should never use any complication code along with normal delivery codes. If there is admission for normal delivery, we have to assign O80 ICD 10 code.
O80- Encounter for Full-term uncomplicated delivery
Chapter 15 ICD codes are used only for complications present during pregnancy. O80 should never be used when we are assigning a code from Chapter 15. This is obvious, if a complication is present, it cannot be called normal and if it is normal then it means there is no complication. Hence, we cannot code a Normal delivery code with any pregnancy complication code.
Read also: How to code Twin Pregnancy in Radiology
Use of Secondary codes with Normal Delivery
Do you know why there are many ICD 10 codes compared to ICD9? Don’t know! Here is the answer; Pregnancy codes are mainly responsible for increasing the number of ICD 10 codes. In ICD 9 we never had any codes for specific trimester, but ICD 10 we have specific codes for first, second and third trimester. In addition, we have an unspecified code, in case the trimester is not documented. In addition, ICD 10 includes new Z3A category codes, which specify the weeks of gestation. Do not forget to use Z3A category codes as secondary code along with normal delivery or pregnancy complication codes, to specify the weeks of gestation. If we are coding for Normal delivery codes we have also code for outcome for delivery codes. These codes are also need to be added with normal or cesarean delivery codes, to specify the outcome for delivery. For example, if a single live healthy baby is born, we have to assign ICD 10 Z37.0.
Z37.0- Single Live birth
Do and Don’t with Normal Delivery and Pregnancy complication codes
Never use a Normal delivery codes with Pregnancy complication (Chapter 15) codes.
Always use Z3A category along with Normal delivery and Pregnancy complication codes.
Do use outcome for delivery codes when the admission is for normal or cesarean delivery.
Do code for the specific trimester codes when it is clearly documented in the report.