OB-GYN ICD-10 Training
June 1 , 2015
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1
Nancy Enos, FACMPE, CPMA, CEMC, CPC-I, CPC is an independent
consultant and coding instructor with 35 years of operations
experience in the practice management field. She joined Ingenix
(formerly LighthouseMD) in 1995 and served as the Director of
Physician Services until 2008.
As an approved PMCC instructor of the American Academy of
Professional Coders, Nancy provides coding certification courses,
outsourced coding, chart auditing, consultative services and
seminars in CPT and ICD-9 coding, evaluation and management
coding and documentation and compliance planning. Nancy
frequently speaks on coding, compliance and reimbursement issues
to the provider community.
Nancy is a Fellow of the American College of Medical Practice
Executives. She is on the Section Steering Committee of MGMA and
is a Past President of MA/RI MGMA. She is the founding President of
the Rhode Island Chapter, AAPC.
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2
Mike Enos, CPC, CPMA, CEMC has over 10 years of experience in
medical coding, billing compliance and revenue cycle management
and has developed a suite of online training courses on Evaluation and
Management, ICD-10 and CPC preparation.
After earning a B.A. from Rhode Island College, Mike pursued three
professional medical coding certifications, including Certified
Professional Coder (CPC), Certified Professional Medical Auditor
(CPMA) and Certified Evaluation and Management Coder (CEMC).
Mike has contributed articles to MGMA Connection Magazine, as well
as presented at MGMA conferences, AAPC chapter meetings and the
New England Quality Care Alliance (NEQCA) Fall Forum. He has served
as a billing compliance specialist with Medsafe, and currently works as
a compliance consultant with Enos Medical Coding.
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OB-GYN ICD-10 Training
Mike Enos, CPC, CPMA, CEMC
Nancy Enos, FACMPE, CPC-I, CPMA, CEMC
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Today’s agenda
• Brief introduction to ICD-10
• Important conventions in the ICD-10 code set
• Chapter-specific guidelines for OB-GYNs
• Clinical examples
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Introduction
• CMS: “On October 1, 2015, the ICD-9 code sets used
to report medical diagnoses and inpatient
procedures will be replaced by ICD-10 code sets.”
– One implementation for all covered by HIPAA (not
applicable to automobile insurance, workers’
compensation, some liability insurance)
– CMS has confirmed – no extensions
– On April 14, Congress passed The Medicare Access and
CHIP Reauthorization Act, which repealed the flawed SGR
formula, clearing the final hurdle for ICD-10
implementation
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Why change from ICD-9?
• ICD-9 has several problems
– After more than 35 years, it is no longer useful for tracking
diseases
– It is out of room: Because the classification is organized
scientifically, each three-digit category can have only 10
subcategories
• Medical science keeps making new discoveries, but there are no
numbers to assign these diagnoses
• ICD-10 expands to seven digits
– Computer science, combined with new, more detailed codes of
ICD-10, will allow for better analysis of disease patterns and
treatment outcomes that can advance medical care
– These same details will streamline claims submissions by
making the initial claim much easier for payers to understand
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Why change from ICD-9?
• Under the sponsorship of the World Health Organization, a
select group of physicians created the basic ICD-10 structure
• Each physician specialty within the U.S. offered input on each
subset of diagnosis codes required
– In most cases, the specialties advocated capturing additional detail
based on information that physicians intuitively use in delivering
patient care
• Greater detail will encourage accurate analysis of health data,
which will help improve the quality and efficiency of patient
care, particularly with increased electronic sharing and
exchange of health data
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Comparing ICD-9 to ICD-10
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Comparison of code sets
ICD-9
ICD-10
3-5 characters
3-7 characters
More than 17,000 codes
More than 155,000 codes
(68,000 are for ICD-10-CM)
First digit may be alpha (E or V only)
or numeric; digits 2-5 are always
numeric
First character is alpha; digits 2-3 are
numeric; 4-7 are alpha or numeric
Limited space for adding new codes
Flexible, new format allows for
expansion
Lacks detail
Very specific
Lacks laterality (right vs. left)
Includes a specific field to identify
laterality, which accounts for one-third
of the new codes
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Reimbursement and quality problems with ICD-9
• Example: A patient presents with a lump in the right
breast
−
−
–
–
Physician bills for a biopsy of the breast
A month later, a lump is discovered in the left breast
ICD-9 does not identify left vs. right
Requires additional documentation
• ICD-10 describes:
– Left vs. right
– Initial encounter, subsequent encounter
– Routine healing, delayed healing, nonunion or
malunion
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ICD-10 changes everything
Episode
of care
Laterality
Severity
Detailed clinical information
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ICD-10 differences
 Combination codes
 Laterality
 Episode of care
 Exact anatomic location
 Clinical details
 Cause/etiology
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Combination codes
• Single code used to classify two diagnoses
– A diagnosis with an associated sign or symptom
– Diagnosis with an associated complication
• Simplifies the number of codes needed to clinically
spell out a condition
– Documentation will need to support all elements
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Combination codes
ICD-10-CM
• E11.41 Type 2 diabetes with diabetic
mononeuropathy
ICD-9-CM
• 250.60 Diabetes with neurological
manifestations, type 2 or unspecified, not
stated as uncontrolled
• 355.9 mononeuritis of unspecified site
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Laterality
• Code descriptions include designations for left, right
and, in many cases, bilateral
• Documentation should always include laterality
when possible
• What additional documentation will be needed?
 Right
 Left
 Bilateral
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Laterality
C50.111 Malignant neoplasm of central portion of right female breast
C50.112 Malignant neoplasm of central portion of left female breast
C50.119 Malignant neoplasm of central portion of unspecified female
breast
• Some ICD-10-CM codes indicate laterality, specifying
whether the condition occurs on the left, right or is
bilateral
• If no bilateral code is provided and the condition is
bilateral, assign separate codes for both the left and right
side
• If the side is not identified in the medical record, assign the
code for the unspecified side
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Laterality
N60.0 Solitary cyst of breast
N60.01 Solitary cyst of right breast
N60.02 Solitary cyst of left breast
Pretty simple, right? What if I told you this simple distinction
between left and right accounts for about 25,000 of the 69,000
codes in ICD-10?
That's right: 25,000 codes in ICD-10 are different only in that
they distinguish between left and right.
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Location
• Sometimes the last digit indicates the specific site:
o N80 Endometriosis
•
•
•
•
•
•
•
•
N80.1 Endometriosis of ovary
N80.2 Endometriosis of Fallopian tube
N80.3 Endometriosis of pelvic perotoneum
N80.4 Endometriosis of rectovaginal septum and vagina
N80.5 Endometriosis of intestine
N80.6 Endometriosis of cutaneous scar
N80.8 Endometriosis other
N80.9 Endometriosis unspecified
• What additional documentation will be needed?
 The specific site of the endometriosis
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Clinical details
• N73.0 Acute parametritis and pelvic cellulitis
• N73.1 Chronic parametritis and pelvic cellulitis
• N73.3 Female acute pelvic peritonitis
• N73.4 Female chronic pelvis peritonitis
• N75.0 Cyst of Bartholin’s gland
• N75.1 Abscess of Bartholin’s gland
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ICD-10 structure
• The expanded number of characters of the ICD-10
diagnosis codes provides greater specificity to
identify disease etiology, anatomic site and severity
• Characters 1-3: Category (“block”)
• Characters 4-6: Etiology, anatomic site, severity or
other clinical detail
• Character 7: Extension, for example: episode of care
or other clinical detail
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Structural change
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Fifth characters
Identifies the most precise level of specificity
Example:
O23.12 Infections of bladder in pregnancy, second trimester
3 – O23 is a category for infections of genitourinary tract in
pregnancy
4 – O23.1 specifies the infection is of the bladder
5 – O23.12 indicates the pregnancy is in the second trimester
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Sixth characters
O24
Diabetes mellitus in pregnancy, childbirth and
the puerperium
O24.0 Pre-existing DM, type 1, in pregnancy,
childbirth and the puerperium
O24.01 Pre-existing DM, type 1, in pregnancy
O24.013 Pre-existing DM, type 1, in pregnancy, third
trimester
Report Z3A – to indicate weeks of gestation
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Seventh character extenders
• The fact that the codes are up to seven characters in length is a
major difference that brings two new considerations: seventh
character extenders and dummy placeholders
• Seventh character extenders are usually a letter and are used to
identify specific information about the clinical episode
• Most of the seventh character extenders related to obstetrics
identify the fetus in cases of multiple gestations:
0 – Not applicable or
unspecified
1 – fetus 1
2 – fetus 2
3 – fetus 3
4 – fetus 4
5 – fetus 5
9 – fetus 9
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A unique twist: the placeholder
• Some codes are seven characters, but no fourth, fifth
or sixth place is necessary, so “x” is a placeholder:
O40.3xx0 — Polyhydramnios, single gestation
O41.01X1 — Oligohydramnios, first trimester, fetus 1
of multiple gestation
• The appropriate seventh character is to be added to
identify the fetus to which the code applies
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Example
Patient with monochorionic twin gestations presents
with ultrasound indicating polyhydramniosis of Twin A
(fetus 1). She is 30 weeks gestation.
• O40.3XX1 — Polyhydramnios, third trimester, fetus 1
• Z3A.30 — 30 weeks gestation of pregnancy
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Unspecified codes
• The doctor has not given enough information in the
documentation
• Differs from “other specified” which means there is
no exact code description for the documentation
• Be careful when using unspecified codes; some
payers may deny claims if an unspecified code is
used (pain in unspecified knee)
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It’s all about the documentation
• The level of evaluation and management (E/M)
service is based on:
 Medical necessity
 Documentation of history, exam and MDM
 Time
• The detail in ICD-10 depends on the information in
the note
• Coders and billers are trained not to use
unspecified codes and are always directed to
query the provider for more detailed information
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Changes by ICD-10-CM chapters
1. Infectious and Parasitic Diseases
2. Neoplasms
3. Diseases of the Blood and Blood-Forming
Organs
4. Endocrine, Nutritional and Metabolic
Diseases
5. Mental and Behavioral Disorders
6. Disease of the Nervous System
7. Diseases of the Eye and Adnexa
8. Diseases of the Ear and Mastoid Process
9. Diseases of the Circulatory System
10. Diseases of the Respiratory System
11. Diseases of the Digestive System
12. Diseases of the Skin and Subcutaneous
Tissue
13. Diseases of the Musculoskeletal
System and Connective Tissue
14. Diseases of the Genitourinary System
15. Pregnancy, Childbirth and the
Puerperium
16. Newborn (Perinatal)
17. Congenital Malformations,
Deformations and Chromosomal
Abnormalities
18. Symptoms, Signs and Abnormal
Clinical and Laboratory Findings
19. Injury, Poisoning and Certain Other
Consequences of External Causes
20. External Causes of Morbidity
21. Factors Influencing Health Status and
Contact with Health Services
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Chapter 14: Diseases of the Genitourinary System
• Chapter 14 includes sublistings for:
– Disorders of the breast (N60-N65)
– Inflammatory diseases of female pelvic
organs (N70-N77)
– Noninflammatory disorders of female
genital tract (N80-N98)
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Disorders of the breast
•
•
•
•
•
•
N60 – Benign mammary dysplasia
N61 – Inflammatory disorders of the breast
N62 – Hypertrophy of breast
N63 – Unspecified lump in breast
N64 – Other disorders of breast
N65 – Deformity and disproportion of
reconstructed breast
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Inflammatory diseases of female pelvic organs
•
•
•
•
•
N70 – Salpingitis and oophoritis
N71 – Inflammatory disease of uterus, except cervix
N72 – Inflammatory disease of cervix uteri
N73 – Other female pelvic inflammatory diseases
N74 – Female pelvic inflammatory disorders in
diseases classified elsewhere
• N75 – Diseases of Bartholin’s gland
• N76 – Other inflammation of vagina and vulva
• N77 – Vulvovaginal ulceration and inflammation in
diseases classified elsewhere
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Noninflammatory disorders of female genital tract
•
•
•
•
•
•
•
•
•
•
N80 – Endometriosis
N81 – Female genital prolapse
N82 – Fistulae involving female genital tract
N83 – Noninflammatory disorders of ovary, fallopian tube
and broad ligament
N84 – Polyp of female genital tract
N85 – Other noninflammatory disorders of uterus, except
cervix
N86 – Erosion and ectropion of cervix uteri
N87 – Dysplasia of cervix uteri
N88 – Other noninflammatory disorders of cervix uteri
N89 – Other noninflammatory disorders of vagina
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Noninflammatory disorders of female genital tract
• N90 – Other noninflammatory disorders of vulva and
perineum
• N91 – Absent, scanty and rare menstruation
• N92 – Excessive, frequent and irregular menstruation
• N93 – Other abnormal uterine and vaginal bleeding
• N94 – Pain and other conditions associated with female
genital organs and menstrual cycle
• N95 – Menopausal and other perimenopausal
disorders
• N96 – Recurrent pregnancy loss
• N97 – Female infertility
• N98 – Complications associated with artificial
fertilization
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Chapter 15: Pregnancy, Childbirth, Puerperium
• Codes from this chapter are for use only on maternal
records, never on newborn records
• The majority of codes in Chapter 15 have a final character
indicating the trimester of pregnancy
– Trimesters
• First – up to 13 weeks, 6 days
• Second – 14 weeks to 27 weeks, 6 days
• Third – 28 weeks to delivery
• All Chapter 15 codes require weeks of gestation reported
with Z3A.--
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Chapter 15: Pregnancy, Childbirth, Puerperium
• A patient is experiencing spotting at 16 weeks, 4 days of
pregnancy.
• O26.85 – Spotting complicating pregnancy
o O26.851 – Spotting complicating pregnancy, first trimester
o O26.852 – Spotting complicating pregnancy, second trimester
o O26.853 – Spotting complicating pregnancy, third trimester
o O26.859 – Spotting complicating pregnancy, unspecified
trimester
• Z3A.16 – 16 weeks gestation of pregnancy
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Chapter 15: Pregnancy, Childbirth, Puerperium
• Chapter 15 codes have sequencing priority over codes
from other chapters
• Additional codes from other chapters may be used in
conjunction with chapter 15 codes to further specify
conditions
• It is the provider’s responsibility to state that the
condition being treated is not affecting the pregnancy
– Should the provider document that the pregnancy is incidental
to the encounter, then code Z33.1, Pregnant state, incidental,
should be used in place of any chapter 15 codes
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Chapter 15: Pregnancy, Childbirth, Puerperium
Complications of pregnancy
• Documentation of conditions/complications of pregnancy will need
to distinguish between pre-existing conditions, or pregnancy-related
conditions.
• When documenting complications of pregnancy, include the
following:
– Condition detail Was the condition pre-existing (i.e. present
before pregnancy)
– Trimester When did the pregnancy-related condition develop?
– Causal relationship Establish the relationship between the
pregnancy and the complication (i.e. preeclampsia)
O99.011
O13.2
O24.012
Anemia complicating pregnancy, first trimester
Gestational hypertension without significant proteinuria, second trimester
Pre-existing diabetes mellitus, type 1, in pregnancy, second trimester
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Chapter 15: Pregnancy, Childbirth, Puerperium
Routine outpatient prenatal visits
• When no complications are present, a code from
category Z34, Encounter for supervision of normal
pregnancy, should be used as the first-listed
diagnosis
– Should not be used in conjunction with chapter 15 codes
Prenatal outpatient visits for high-risk patients
• For patients with high-risk pregnancies, a code from
category O09, Supervision of high-risk pregnancy,
should be used as the first-listed diagnosis
• Secondary chapter 15 codes may be used in
conjunction with these codes if appropriate
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Chapter 15: Pregnancy, Childbirth, Puerperium
Episodes when no delivery occurs
• Principal diagnosis should correspond to the principal complication of
the pregnancy which necessitated the encounter
When a delivery occurs
• Principal diagnosis should correspond to the main circumstances or
complication of the delivery
• In cases of cesarean delivery, the selection of the principal diagnosis
should be the condition established after study that was responsible
for the patient’s admission
– If the reason for the initial encounter was unrelated to the condition resulting
in cesarean delivery, report that condition as the principal diagnosis
Outcome of delivery
• A code from category Z37, Outcome of delivery, should be included
on every maternal record when a delivery has occurred
– Not to be used on subsequent records or on the newborn record
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Chapter 15: Pregnancy, Childbirth, Puerperium
Diabetes mellitus in pregnancy
• Significant complicating factor in pregnancy
• Pregnant women who are diabetic should be assigned a
code from category O24, Diabetes mellitus in pregnancy,
childbirth, and the puerperium, first, followed by the
appropriate diabetes code(s) (E08 - E13) from Chapter 4
Long term use of insulin
• Code Z79.4, Long-term (current) use of insulin, should
also be assigned if the diabetes mellitus is being treated
with insulin
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Chapter 15: Pregnancy, Childbirth, Puerperium
Gestational (pregnancy induced) diabetes
• Can occur during the second and third trimester of pregnancy in
women who were not diabetic prior to pregnancy
• Can cause complications in the pregnancy similar to those of preexisting diabetes mellitus
• Puts the woman at greater risk of developing diabetes after the
pregnancy
• Codes for gestational diabetes are in subcategory O24.4, Gestational
diabetes mellitus
– Codes under subcategory O24.4 include diet controlled and insulin
controlled
– If a patient with gestational diabetes is treated with both diet and
insulin, only the code for insulin-controlled is required
• Code Z79.4, Long-term (current) use of insulin, should not be
assigned with codes from subcategory O24.4
• An abnormal glucose tolerance in pregnancy is assigned a code from
subcategory O99.81, Abnormal glucose complicating pregnancy,
childbirth, and the puerperium
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Chapter 15: Pregnancy, Childbirth, Puerperium
Encounter for full-term uncomplicated delivery
• Code O80, Encounter for full-term uncomplicated delivery,
should be assigned when a woman is admitted for a full-term
normal delivery and delivers a single, healthy infant without
any complications antepartum, during the delivery or
postpartum during the delivery episode
– Code O80 is always a principal diagnosis
Uncomplicated delivery with resolved antepartum complication
• Code O80 may be used if the patient had a complication at
some point during the pregnancy, but the complication is not
present at the time of the admission for delivery
Outcome of delivery for O80
• Z37.0, Single live birth, is the only outcome of delivery code
appropriate for use with O80
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Chapter 15: Pregnancy, Childbirth, Puerperium
Peripartum and postpartum periods
• The postpartum period begins immediately after
delivery and continues for six weeks following delivery
• The peripartum period is defined as the last month of
pregnancy to five months postpartum
Peripartum and postpartum complication
• A postpartum complication is any complication
occurring within the six-week period
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Chapter 15: Pregnancy, Childbirth, Puerperium
Abuse in a pregnant patient
• For suspected or confirmed cases of abuse of a pregnant
patient, a code(s) from the following subcategories
should be sequenced first:
– O9A.3: Physical abuse complicating pregnancy, childbirth, and
the puerperium
– O9A.4: Sexual abuse complicating pregnancy, childbirth, and
the puerperium
– O9A.5: Psychological abuse complicating pregnancy, childbirth,
and the puerperium
• This should be followed by appropriate codes (if
applicable) to identify any associated current injury due
to physical abuse or sexual abuse, and the perpetrator
of abuse
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Chapter 15: Pregnancy, Childbirth, Puerperium
Alcohol use, substance use and tobacco dependence
•
•
Documentation should capture the mother’s use (or non-use) of tobacco,
alcohol and substances along with the associated risk to the child
When codes associated with category O99.33, smoking (tobacco)
complicating pregnancy, are used, a secondary code from the following
categories should also be assigned:
–
–
•
F17, nicotine dependence
Z72.0, tobacco use
In a similar manner, when codes under category O99.31, alcohol use
complicating pregnancy, are used, a secondary code from category F10,
alcohol-related disorders, should also be assigned
O99.311
Alcohol use complicating pregnancy, first trimester
O99.331
Smoking (tobacco) complicating pregnancy, first trimester
O35.4XX1
Maternal care for (suspected) damage to fetus from alcohol, fetus 1
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Chapter 15: Pregnancy, Childbirth, Puerperium
Vomiting
• The time frame for differentiating early and late
vomiting in pregnancy has been changed from 22 to 20
weeks
O21.0
Mild hyperemesis
gravidum
Hyperemesis gravidarum, mild or unspecified,
starting before the end of the 20th week of
gestation
Hyperemesis gravidarum Hyperemesis gravidarum, starting before the
O21.1
with metabolic
end of the 20th week of gestation, with
disturbance
metabolic disturbance
O21.2
Late vomiting of
pregnancy
Excessive vomiting starting after 20 completed
weeks of gestation
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Chapter 15: Pregnancy, Childbirth, Puerperium
Abortion
• The timeframe for a missed abortion (vs. fetal death) has
changed from 22 to 20 weeks
• In ICD-10-CM, an elective abortion is now described as an
elective termination of pregnancy
• There are four spontaneous abortion definitions in ICD-10;
use the appropriate definition in your documentation:
– Missed abortion: No bleeding, os closed
– Threatened abortion: Bleeding, os closed
– Incomplete abortion: Bleeding, os open, products of
conception (POC) are extruding
– Complete abortion: Possible bleeding or spotting, os
closed, all POC expelled
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Chapter 21: Factors Influencing Health Status
and Contact with Health Services
Intent of encounter
When documenting intent of encounter, include the following:
• Type of encounter: e.g., OB or GYN, contraception management,
postpartum care
• Complications: Note any abnormal findings with examination
Z30.011
Encounter for initial prescription of contraceptive pills
Z31.82
Encounter for Rh incompatibility status
Z39.1
Encounter for care and examination of lactating mother
Z34.01
Encounter for supervision of normal first pregnancy, first trimester
Z32.01
Encounter for pregnancy test, result positive
Z33.2
Encounter for elective termination of pregnancy
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Obstetrics Example No. 1
Persons
encountering
health
services
inincircumstances
Venous
complications
and
hemorrhoids
pregnancy
Other
maternal
disorders
predominantly
Hemorrhoids
in
pregnancy
Weeks of gestation
ofpregnancy
pregnancy, 10-19
related
totoreproduction
related
Hemorrhoids
during
16 weeks
O22.0
Varicose
veins
ofmanagement
lowerpregnancy,
extremity in pregnancy
Z30
forincontraceptive
O20 Encounter
Hemorrhage
early pregnancy
O22.40
Hemorrhoids
in pregnancy, unspecified
Z31
Encounter
for procreative
management
O22.1
Genital
varices
in pregnancy
O21 Excessive
vomiting
in pregnancy
Z3A.10
10 weeks gestation
of pregnancy
Z3A.15
weeks gestation
pregnancy
Z32
Encounter
forat
pregnancy
test and 2/7
childbirth
and15
childcare
instructionofCode
for
A
woman
16
weeks
days
of
her
O22.2
Superficial
thrombophlebitis
in
pregnancy
trimester
O22 Venous complications and hemorrhoids in pregnancy
Z33 Pregnant
state
Z3A.11
11
weeks
gestationinof pregnancy
Z3A.16
16 weeks gestation
of pregnancy
O22.42
Hemorrhoids
in pregnancy,
Code
for
problem
problem
in
O23
Infections
of
genitourinary
tract
in
pregnancy
O22.3
Deep
phlebothrombosis
in
pregnancy
pregnancy
presents
to
her
OB/GYN
for
Z34
Encounter
for
supervision
of
normal
pregnancy
O22.41
Hemorrhoids
in
pregnancy,
first
trimester
Z3A.12 pregnancy
12 weeks gestation of pregnancy
Z3A.17
17 weeks
gestation of pregnancy
second
trimester
pregnancy
O24
Diabetes
mellitus
in
pregnancy,
childbirth,
and
the
puerperium
O22.4
Hemorrhoids
in
pregnancy
Z36
Encounter
for antenatal screening
of mother
hemorrhoids.
O22.42
Hemorrhoids
in Z3A.16
pregnancy,
second
trimester
Z3A.13
13
weeks
gestation
of pregnancy
Z3A.18
18 weeks
weeks
gestation
of pregnancy
Code
for
weeks
of
16
gestation
of for
O25
Malnutrition
in
pregnancy,
childbirth
and
the
puerperium
Z37
Outcome
of
delivery
Code
O22.5
Cerebral
venous
thrombosis
in
pregnancy
Z3A.14
14
weeks
gestation
ofconditions
pregnancy
Z3A.19
weeks
gestation
of pregnancy
Z38
infants
to place
of birth
and 19
type
ofthird
delivery
O22.43
Hemorrhoids
in
pregnancy,
trimester
O26 Liveborn
Maternal
care
foraccording
other
predominantly
related
to
pregnancy
gestation
pregnancy
weeks of
O22.8 Other venous complications in pregnancy
Z39
for maternal
postpartum
careofand
examination
O28 Encounter
Abnormal findings
on antenatal
screening
mother
gestation
O22.9
Venous
complication
in
pregnancy,
unspecified
Z3A
Weeks
of
gestation
O29 Complications of anesthesia during pregnancy
Z
O
32
A
2
14
62
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51
Obstetrics Example No. 2
Chief Complaint
Vaginal discharge with odor x 1 week.
Inflammatory
of
Female
Pelvic
Organs
Other
inflammation
ofsubcutaneous
vagina
and vulva
Diseases
of Potential
theDiseases
skin
and
tissueto
Persons
with
Health
Hazards
Related
Pruritus
N70N76.0
– Salpingitis
and
oophoritisvaginosis
Communicable
Diseases
L20
Atopic
dermatitis
L27 Dermatitis
due to
Bacterial
case
Acute
vaginitis
L29.0
Pruritus
ani
N71Z20
– Inflammatory
disease
of uterus, except
cervixto communicable
Contact
with
andchronic
(suspected)
exposure
L21
Seborrheic
dermatitis
substances
taken internally
N76.1
Subacute
and
vaginitis
Pruritusdisease
scrotiof cervix uteri
N72L29.1
– Inflammatory
diseases
L22
Diaper
dermatitis
L28 Lichen
simplex chronicus
N76.2
vulvitis
N73L29.2
– OtherAcute
female
pelvic
inflammatory
diseases
Pruritus
vulvae
N76.Ø
Acute
vaginitis
Z21
Asymptomatic
immunodeficiency
virus
[HIV]
L23
Allergic
contact
dermatitis
and prurigo
Subacute
andhuman
chronic
vulvitis
N74N76.3
– Female
pelvic inflammatory
disorders
in diseases
classified
L29.3
Anogenital
pruritus,L29
unspecified
infection
statusofdermatitis
elsewhere
L24
IrritantAbscess
contact
Pruritus
N76.4
vulva
L29.2
Vulvar,
pruritis
N75L29.8
– Diseases
ofofcontact
Bartholin’s
gland
Other
pruritus
Z22
Carrier
infectious
disease
L25
Unspecified
L30 Other
and unspecified
N76.5
Ulceration
of vagina
N76Z23
– Other
inflammation
of
vagina
and
vulva
1
Encounter
forof
immunization
L29.9
Pruritus,
unspecified
dermatitis
dermatitis
N76.6
Ulceration
vulva
N77 – Vulvovaginal ulceration and inflammation in diseases classified
Z28
Immunization
not inflammation
carried out
Z23
Encounter
for and
immunization
L26
Exfoliative
dermatitis
N76.8
Other
specified
ofunderimmunization
vagina and vulva
elsewhere
History
28 year female, established patient, presents complaining of a thin, grayish-white vaginal discharge with a noticeable fishy smell
accompanied by vulvar itching. She first noticed symptoms about 1 ½ weeks ago. Patient states she tried to self-treat using an
over-the-counter yeast preparation approximately 1 week ago without relief of symptoms. She denies any history of similar
symptoms in the past.
LMP: occurred 2 weeks ago, normal cycle for her. Last PAP exam 8 months ago, normal. No previous mammograms.
Social history: Physically active. She is in a new monogamous relationship with male partner x 5 weeks, sexually active with
protection. Denies history of STIs. Admits to frequent douching and bubble baths.
Immunizations: not immunized for HPV.
No tobacco, alcohol, or other drug use.
Review of systems negative except as noted above.
Exam
Vital Signs: BP 128/64, T 98.7°F, Ht. 63 in. Wt. 108 lbs.
Well-groomed, A&Ox3.
Pelvic: External exam-vulvar redness, no vulvar edema and no adherent white clumps present; Speculum exam – vaginal walls
pink, cervix intact, closed os, thin gray and foul smelling discharge noted in vaginal canal. Swab specimen obtained for microscopy
exam. Bimanual exam – no pelvic tenderness, uterus smooth, uterus and adnexa are normal in size, ovaries not palpable.
Labs in office: Urine hCG – Negative; wet prep – Positive whiff test, clue cells and leukocytes present; negative for yeast; vaginal pH
elevated.
status
Assessment and Plan
Bacterial vaginosis.
Vulvar pruiritis
Prescribed 7-day metronidazole.
Discussed and administered HPV vaccine in office today.
Provided vaginal hygiene pamphlet. Instructed patient to avoid douching and use of bubble bath products. Refrain from
intercourse for one week after starting metronidazole. Other activities as normal.
LZ
N
72
693
02
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52
Obstetrics Example No. 3
OTHER
MATERNAL
DISORDERS
PREDOMINANTLY
Pre-existing
diabetes
mellitus,
2, in
Diabetes
mellitus
in pregnancy,
childbirth,
Persons
encountering
health
services
intype
circumstances
Pre-existing
diabetes
mellitus,
type
2, in
Weeks
of
gestation
of
pregnancy,
10-19
RELATED
TO
PREGNANCY
related
to
reproduction
pregnancy,
childbirth
and
the
puerperium
and
the
puerperium
pregnancy
E11.0
Type
Diabetes
2
diabetes
mellitus
complicating
with
hyperosmolarity
pregnancy
Z30
Encounterdiabetes
for
contraceptive
management
E08
Diabetes
due
to
underlying
O20
Hemorrhage
inmellitus
early
pregnancy
O24.0
Pre-existing
mellitus,
type
1,Z3A.15
in pregnancy,
childbirth
the for
Z3A.10
10
weeks
gestation
of
pregnancy
15 weeks
gestation and
ofCode
pregnancy
E11.2
Type
2
diabetes
mellitus
with
kidney
complications
Z31
Encounter
for procreative
management
O21
Excessive
vomiting
in
pregnancy
puerperium
A
woman
with
well-controlled
O24.111
Pre-existing
diabetes
mellitus,
type
2, ininstruction
problem
in
Z3A.11
11 weeks
gestation
of
pregnancy
Z3A.16
16 and
weeks
gestation
of pregnancy
condition
Encounter
for pregnancy
test
and
childbirth
childcare
E11.3
Type
2complications
diabetes
mellitus
with
ophthalmic
complications
O24.1
Pre-existing
diabetes
mellitus,
type
2,
in
pregnancy,
childbirth
and
the
O22Z32
Venous
and
hemorrhoids
in
pregnancy
Pre-existing
diabetes
pregnancy,
first
trimester
Z3A.12
12
weeks
gestation
of
pregnancy
Z3A.17
17
weeks gestation pregnancy
of pregnancy
Z33
Pregnant
type
2Pre-existing
diabetes
becomes
pregnant.
puerperium
O23
Infections
ofstate
genitourinary
inneurological
pregnancy
O24.11
diabetes
mellitus,
type
2, incomplications
pregnancy
E11.4
Type
2 diabetes
mellitustract
with
Type
2 diabetes
mellitus
DIABETES
MELLITUS
E09
Drug
or
chemical
induced
diabetes
mellitus
O24.112
Pre-existing
diabetes
mellitus,
type
2,
in
O24.112
mellitus,
type
2,
in
Z3A.13
13 weeks
gestation
ofpregnancy,
pregnancy
Z3A.18
18
weeks
gestation
of pregnancy
Z34
Encounter
for supervision
normal
pregnancy
O24.3
Unspecified
pre-existing
diabetes
mellitus
intype
pregnancy,
childbirth
and for
the
thofweek
O24
Diabetes
mellitus
in
childbirth,
and
the
puerperium
Code
O24.12
Pre-existing
diabetes
mellitus,
2,
in
childbirth
E11.5
Type
2
diabetes
mellitus
with
circulatory
complications
She
is
now
in
her
16
of
pregnancy,
second
trimester
E10
Type
1 gestation
diabetes
mellitus
Z36
Encounter
for
screening
of
mother
puerperium
pregnancy,
second
trimester
Z3A.14
14 weeks
of pregnancy
Z3A.19
19 weeks
gestation of pregnancy
O25
Malnutrition
in antenatal
pregnancy,
childbirth
and
the
puerperium
O24.13
Pre-existing
diabetes
mellitus,
type
2,
in
puerperium
E11.6
Type
2
diabetes
mellitus
with
other
specified
complications
O24.113
Pre-existing
diabetes
mellitus,
type
2,the
incomplications
pregnancy.
O24.4
Gestational
diabetes
mellitus
Z37
Outcome
of delivery
O26
Maternal
care
for
other
conditions
predominantly
related
to
E11
Type
2
diabetes
mellitus
pregnancy,
third
trimester
E11.8
Type
2 diabetes
mellitus
with
unspecified
complications
Type
2place
diabetes
mellitus
O24.8
Other
pre-existing
mellitus
inof
pregnancy,
childbirth,
and
the for
Z38
Liveborn
infants diabetes
according
to
birth and
type
of delivery
pregnancy
Code
E11.9
O24.119
Pre-existing
diabetes
mellitus,
type
2, in weeks of
puerperium
Z39
Encounter
for maternal
postpartum
caremellitus
and examination
E11.9
Type
2 diabetes
mellitus
without
complications
O28
Abnormal
findings
on
antenatal
screening
of
mother
E13
Other
specified
diabetes
without
complications
O24.9
Unspecified
diabetes
mellitus
in during
pregnancy,
childbirth and the puerperium
pregnancy,
unspecified
trimester
Weeks
of gestation
O29Z3A
Complications
of anesthesia
pregnancy
Z3A.16
EZ
O
123
1A
4
16 weeks gestation of
pregnancy
91
16
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gestation
2
53
Questions?
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54
Preparing for ICD-10 with Greenway Health
Christina Golden,
Product Marketing
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57
ICD-10 Training
• Tier 1 – ICD-10 videos, FAQ’s and overview
documents
• Tier 2 – Virtual Interactive Academy Training, ICD-10
videos, FAQ’s and overview documents
• Tier 3 – One to one workflow training (remote and
onsite), VIA Training, ICD-10 videos, FAQ’s and
overview documents
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Not for distribution except to authorized persons.
60