Coding Tip: Obstetric Tidbits for PCS

by | Feb 7, 2019 | Coding Tips, Education, ICD-10, Kim Carrier | 0 comments

Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer

Last week, we looked at tidbits for reporting the ICD-10-CM codes for pregnancy/obstetric records. Now we will look at some for the ICD-10-PCS reporting of these records.

In reporting the appropriate ICD-10-PCS codes, a coder must know what is included in the terminology of products of conception (POC). The POC include all components of pregnancy, including the fetus, embryo, amnion, umbilical cord and the placenta.

Helpful Tidbits for Coding OB Procedures

  • Procedures performed on the products of conception are coded to the Obstetrics section
  • Procedures performed on the pregnant female other than the products of conception are coded to the appropriate root operation in the Medical and Surgical section
  • Curettage of the endometrium is coded in the Obstetrics section, to the root operation Extraction and the body part Products of Conception, Retained
  • Evacuation of retained products of conception is coded to the Obstetrics section, to the root operation Extraction and the body part Products of Conception, Retained
  • Pitocin administration given to induce labor should be coded separately
  • Pitocin administration given to augment active labor is NOT coded separately
  • Delivery of placenta only (baby delivered outside of hospital) is coded as delivery of products of conception since ICD-10-PCS does not differentiate between delivery of the baby and the placenta
  • Whenever there is assisted delivery it should be coded
  • Peri-urethral laceration repair is coded as repair of vulva since peri-urethral is vulvar tissue
  • Vacuum assistance during cesarean section is not coded separately
  • When more than one location is documented to have an obstetric tear, code the deepest layer involved in the tear
  • Repair of second degree perineal laceration occurring during vaginal delivery is coded as open approach since the laceration has cut through the external body layers exposing muscle (based on the definition of second degree perineal laceration)
  • High vaginal wall lacerations are not seen/coded often

References
ICD-10-CM/PCS Coding Clinic®, Fourth Quarter 2018 Page: 49-51
ICD-10-CM/PCS Coding Clinic®, Fourth Quarter 2013 Page: 120
ICD-10-CM/PCS Coding Clinic®, Second Quarter 2014 Page: 9
ICD-10-CM/PCS Coding Clinic®, Fourth Quarter 2014 Pages: 17-19 and 43-44
ICD-10-CM/PCS Coding Clinic®, Third Quarter 2017 Page: 5
ICD-10-CM/PCS Coding Clinic®, Second Quarter 2016 Page: 33-34
ICD-10-CM/PCS Coding Clinic®, First Quarter 2016 Page: 8
ICD-10-PCS Official Guidelines for Coding and Reporting FY 2019

Happy Coding!

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.

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