March 2, 2015

Clinical Documentation Improvement by Service – Obstetrics and Gynecology – Does Your Documentation Deliver in this Specialty?

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EDITOR’S NOTE: This is the fifth article in a series of articles on clinical documentation improvement by clinical service.

The American Health Information Management Association (AHIMA) Hill Day will be held on March 24, 2015, when ICD-10 implementation will be a high-priority topic. Obstetrics and gynecology codes have undergone major revisions and now may present some challenges under ICD-10-CM/PCS. What are the required documentation updates? Let’s take a look at some examples.

 

Pregnancy without complications: There are still key terms allowing for the coding of an uncomplicated pregnancy; they are the same as in ICD-9-CM. Such an episode should be a delivery with no or minimal assistance, with or without episiotomy, no fetal manipulation, no instrumentation (e.g. forceps), spontaneous labor, full term, with a single, live-born fetus and cephalic presentation.   

Pregnancy with complications: The OB/GYN community has been asking for codes that are trimester-based, and ICD-10-CM delivers (pun intended) on that request. Generally, documentation is very comprehensive with regard to the trimester of pregnancy. The provider should always be aware of the patient’s trimester when completing documentation. The unspecified trimester codes may be monitored to indicate opportunities for documentation improvement. The final character in the code reflects the current trimester of the patient based on the ICD-10-CM Official Coding Guidelines for Coding and Reporting for the 2015 fiscal year. If the patient’s complications are preexisting (meaning present prior to the pregnancy), that information must be documented for code assignment. For example, for pregnancy complicated by hypertension, the code could vary from O16 (pregnancy with hypertension) to O10.91 (pregnancy with preexisting hypertension), based on the documentation. Pregnancy and diabetes are another complication for which a preexisting condition will impact code assignment. Remember that a pregnant woman is considered “elderly” when she is 35 or older, and that this is considered a complication.

Multiple gestations: In ICD-9-CM, multiple gestations were indicated by the code, but no information regarding a specific fetus could be identified. ICD-10-CM has added a seventh, numeric character to identify a specific fetus associated with a specific complication. There is no intent that the fetus numbers will be consistent from episode to episode, however. Organizations should be reinforcing the documentation of a fetus number when multiple gestations are involved.

In-utero surgery: A medical record is not created for a fetus that has surgery. These codes are captured on the mother’s record. In ICD-10, the diagnosis code will start with O35, which specifies the body system involved. The procedure code will be captured using ICD-10-PCS (if the case is an inpatient) and is submitted on the mother’s chart. The key information when documenting an in-utero procedure is the specific body system on which the procedure is performed.

Fibroid uterus: This condition requires a hysterectomy from time to time. There is further specification of this condition with regard to the type of fibroid – submucosal, intramural, and subserosal are the specified types in ICD-10-CM (as well as ICD-9-CM). This specificity provides information regarding where the benign neoplasm is growing. The term “intramural” identifies that the fibroid is in the muscular wall; “submucosal” identifies that the growth is just under the interior surface; “subserosal” locates the growth on the outside wall of the uterus.

Delivery: There are not many changes in coding delivery other than recognizing that for procedures, the fetus and placenta are “products of conception.” The root operation for delivery is Delivery when it occurs vaginally. The root operation for Cesarean sections and forceps delivery is Extraction.

Obstetric repairs: The obstetrical repairs are not coded in the Obstetrics chapter but from the Medical and Surgical Section. The documentation regarding the location of the specific obstetrical laceration is important to assigning an accurate code. 

Hysterectomy: One key anomaly for coding and documenting hysterectomy is that the resection of the cervix is coded separately from the resection of the uterus. The surgeon should clearly identify the resection of both anatomic sites in the operating technique. If the surgeon does not remove all of the uterus or the cervix, then the root operation will be Excision.

Endovascular embolization of fibroids: These procedures are frequently performed on an outpatient basis. The key to this procedure is the typical objective of the procedure – occluding the vessel so that the fibroid shrinks. The other objective may be to restrict the vessels, but the documentation should clearly outline the objective. The specific location of the occlusion should be identified, as laterality does impact the procedure code assignment (see Table 04L in ICD-10-PCS).

This exploration of obstetrics and gynecology coding reveals that there are dramatic changes regarding these conditions and procedures. But ICD-10-CM/PCS delivers in providing more current terminology for these clinical services. It is important to acknowledge that the documentation of trimester is significant. The next article in the series will cover behavioral health.

 

Laurie Johnson, MS, RHIA, CPC-H, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer

Laurie M. Johnson, MS, RHIA, FAHIMA is currently a senior healthcare consultant for Revenue Cycle Solutions, based in Pittsburgh, Pa. Laurie is an American Health Information Management Association (AHIMA) approved ICD-10-CM/PCS trainer. She has more than 35 years of experience in health information management and specializes in coding and related functions. She has been a featured speaker in over 40 conferences. Laurie is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays.

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