Chapter 15 Part 2 Coding Guidelines: Cesarean Delivery

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 ICD-10-CM Coding Guidelines: Cesarean Delivery


Cesarean delivery, also known as a C-section, has specific coding guidelines that determine the selection of principal diagnosis. Here are some examples illustrating each set of rules:


Cesarean delivery with a condition necessitating the procedure:


Rule: 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.

Example: A maternal patient with diet-controlled gestational diabetes is admitted at 38 weeks' gestation in obstructed labor due to footling breech presentation. A cesarean section is performed for the malpresentation.

Code:

O64.8XX0: Obstructed labor due to other malposition and malpresentation, fetus not applicable or unspecified

O24.420: Gestational diabetes mellitus in childbirth, diet controlled

Z3A3.38: 38 weeks gestation of pregnancy

Z37.0: Single live birth

Explanation: The obstructed labor necessitated the cesarean delivery, so the principal diagnosis is O64.8XX0.

Cesarean delivery unrelated to the reason for admission/encounter:


Rule: If the reason for the admission/encounter was unrelated to the condition resulting in the cesarean delivery, the condition related to the reason for the admission/encounter should be selected as the principal diagnosis.

Example: At 39 weeks' gestation, an obstetric patient presents with hemorrhage with coagulation defect. The next day, the patient goes into labor and eventually delivers via cesarean section due to an arrested active phase of labor.

Code:

O46.003: Antepartum hemorrhage with coagulation defect, unspecified, third trimester

O62.1: Secondary uterine inertia

Z3A.39: 39 weeks gestation of pregnancy

Z37.0: Single live birth

Explanation: The patient was admitted because of the antepartum hemorrhage with coagulation defect. The arrested active phase of labor, although the reason for the cesarean delivery, developed later during the stay.

Cesarean delivery without medical indication (elective):


Rule: Occasionally, a cesarean section may be performed without a medical indication. In such cases, assign code O82, Encounter for cesarean delivery without indication, as the principal diagnosis.

Example: A patient elects to have a low cesarean section due to fear of a vaginal delivery.

Code:

O82: Encounter for cesarean delivery without indication

Z37.0: Single live birth

Explanation: As there is no medical condition that resulted in the cesarean delivery, code O82 is assigned as the principal diagnosis.

Planned cesarean delivery between 37 and 39 weeks:


Rule: Code O75.82 is assigned to describe a planned cesarean delivery when the onset of labor occurs after 37, but before 39, completed weeks of gestation. This allows for data collection for quality markers for elective cesarean deliveries performed during this time frame.

Example: A planned cesarean delivery is scheduled for a patient at 38 weeks' gestation.

Code:

O75.82: Other specified complications of labor and delivery, antepartum condition or complication

Z3A.38: 38 weeks gestation of pregnancy

Z37.0: Single live birth



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