Chapter 15 Part 3

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 ICD-10-CM Coding Guidelines: Coding for Elderly or Young Gravida on Encounters When the Patient Delivers


Coding for encounters during childbirth involving elderly (35 years or older) or young (younger than 16) gravida patients follows specific guidelines. Here are examples illustrating each set of rules:


Elderly gravida (35 years or older) or young gravida (younger than 16):


Rule: ICD-10-CM does not have specific codes for encounters during delivery when the patient falls into these age categories. Codes from category O09, Supervision of high-risk pregnancy, are only intended for use during the prenatal period. Assign applicable complication codes from Chapter 15 for complications during labor or delivery as a result of a high-risk pregnancy. If there are no complications during the labor or delivery episode, assign code O80, Encounter for full-term uncomplicated delivery.

Example: A patient who is 38 years old gives birth without any complications.

Code: O80: Encounter for full-term uncomplicated delivery

Final character for trimester:


Rule: Most codes from Chapter 15 have a final character indicating the trimester of pregnancy. The assignment of the final character should be based on the provider's documentation of the trimester or number of weeks.

Example: A patient is admitted at 27 6/7 weeks' gestation for hemorrhaging from partial placenta previa. Three days after admission, at 28 1/7 weeks' gestation, she develops gestational hypertension.

Code:

O44.32: Partial placenta previa with hemorrhage, second trimester

O13.3: Gestational (pregnancy-induced) hypertension without significant proteinuria, third trimester

Z3A.27: 27 weeks gestation of pregnancy

Explanation: The patient presented with hemorrhaging from partial placenta previa in her 27th week, falling within the second trimester. Gestational hypertension developed three days later when the patient was in her 28th week, considered the third trimester.

Note: The examples provided are for illustrative purposes and may not cover all possible scenarios. It is essential to review the complete documentation and adhere to the specific guidelines for accurate coding.







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