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OBGYN

Ch 2: Neoplasms

ICD-9-CM

Anatomical site
Histologic behavior:

  • Malignant Primary
  • Malignant Secondary
  • In situ
  • Benign
  • Uncertain
  • Unspecified behavior

Skin neoplasms:

  • Basal cell carcinoma
  • Squamous cell carcinoma
  • Specified type NEC

Ch 2: Neoplasms

ICD-10-CM Requirements

General Documentation:

  • Anatomical Site
  •  Laterality (left, right)
  • Histologic behavior:
    – Benign
    – Malignant, primary and secondary sites if metastatic
    – In situ
    – Uncertain
    – Unspecified behavior
  • Histologic Type:
    – Carcinoma
    – Basal Cell
    – Squamous Cell
    – Adenoma
  • Complications or Adverse effects of antineoplastic or immunosuppressive drugs
  • Previous excision or eradication

Breast, in-situ, document:

  • Lobular
  • Intraductal

Leukemia, Multiple Myeloma, Malignant plasma cell neoplasms, document:

  • Relapse
  • Remission
  • Not having achieved remission

Ch 2: Neoplasms

Notes

Pathologists may need to work with their referring physician to obtain this information.
When patients have more than one malignant tumor in the same organ document the primary and metastatic disease.

Ch 14: GU Kidney Disease

ICD-9-CM
  •  Chronic
  •  Stage

Ch 14: GU Kidney Disease

ICD-10-CM Requirements

Chronic Kidney Disease, document:

  •  Stage 1
  • Stage 2 (mild)
  •  Stage 3 (moderate)
  • Stage 4 (severe)
  •  Stage 5
  •  Co-morbidities (e.g. DM, HTN)
  •  Specify any associated kidney failure

Urinary Incontinence, document:

  •  Stress
  •  Urge
  •  Without sensory awareness
  •  Post-void dribbling
  •  Nocturnal enuresis
  •  Continuous leakage
  •  Mixed
  •  Overflow

Hematuria, document:

  •  Recurrent
  •  Persistent
  •  Any applicable underlying condition(s)

Neurogenic bladder, document:

  •  Uninhibited
  •  Reflex
  •  Flaccid
  •  Any associated urinary incontinence

Prolapse, document:

  • Site
  •  Complete (3rd degree) or incomplete (1st/2nd degree)

Ch 14: GU Kidney Disease

Notes

Codes from Chapter 14 may be used throughout the life of the patient. If a congenital anomaly has been corrected, a personal history code should be used to identify the history of the anomaly.

Ch 15: Obstetrics & Gynecology

ICD-9-CM
  • Pregnancy specified as episode of care.
  • Missed abortion defined as fetal death (before 22
    weeks).
  •  Weeks of pregnancy (not reported).
  •  Abortions
  •  Current conditions complicating pregnancy.
  •  Diabetes mellitus in pregnancy

Ch 15: Obstetrics & Gynecology

ICD-10-CM Requirements

General Documentation:

  • Episode of Care, document:
    – Trimester of pregnancy, for the current encounter
    – Number weeks gestation
  •  If pregnancy is Incidental, i.e. not the reason for encounter
  •  Pre-existing conditions versus conditions due to the pregnancy
  • Condition that resulted in the performance of a cesarean delivery
  •  Number of fetus’
  •  Outcome of delivery

Termination of pregnancy and Spontaneous Abortions, document:

  •  Type of termination
  •  Type of abortion and completion status incomplete/complete
  •  Retained products of conception following abortion
  •  Complications leading to abortion

Premature Rupture of Membranes, document:

  •  Onset of labor within 24 hours of rupture
  •  Onset of labor more than 24 hours of rupture

Gestational diabetes, document:

  •  Diet controlled
  •  Insulin controlled

Pre-eclampsia, document:

  •  Mild to moderate
  •  Severe
  •  HELLP

Malposition, document:

  •  Disproportion
  •  Maternal condition

Ch 15: Obstetrics & Gynecology

Notes

Trimester:

  • 1st trimester – less than 14 weeks 0 days
  •  2nd trimester – 14 weeks 0 days to less than 28 weeks 0 days
  •  3rd trimester – 28 weeks 0 days until delivery

Several categories require a 7th character code for single gestations and multiple gestations:

0 – not applicable or unspecified 1 – fetus 1
2 – fetus 2
3 – fetus 3
4 – fetus 4
5 – fetus 5
9 – other fetus
Missed abortion defined as fetal death (before 20 weeks)

Ch 16: Perinatal

ICD-9-CM

Ch 16: Perinatal

ICD-10-CM Requirements

General Documentation:

  •  Conditions that have their origin in the fetal or perinatal period (defined as before birth through the 28th day following birth).
  •  Documentation of the listed maternal conditions is specified as the cause of confirmed morbidity or potential morbidity.

Ch 16: Perinatal

Notes

Conditions listed in Chapter 16 are never for use on the maternal record.
Conditions listed in Chapter 16 may be used throughout the life of the patient if the condition is still present.

Ch 21: Factors Influencing Health

ICD-9-CM

ICD-9 V-codes:

  •  Screening
  •  History of
  •  Contact/Exposure
  •  Follow-up
  •  Pre-Operative

Ch 21: Factors Influencing Health

ICD-10-CM Requirements

General Documentation:

  •  Specific purpose for receiving services
  •  Circumstance that affects the patient’s health status but is not a current illness or injury. Key Terms include:
    – Examination, History, Fitting, Status, Screening, etc…
  •  Contact/Exposure: document if with or suspected to communicable disease.
  •  Inoculations and vaccinations document if:
    – Prophylactic inoculation against disease, or
    – Screening for patient without sign or symptom (e.g. encounter of screening mammogram for malignant neoplasm of breast)
  • Documenting “History of” indicates the condition no longer exists but is being monitored) (e.g. personal history of malignant neoplasm of breast)
  •  Documenting “Follow-up” indicates continued surveillance following completed treatment (e.g. Encounter for routine postpartum follow-up)
  •  Pre-operative for patients receiving preoperative evaluation only (e.g. Encounter for pre-procedural exam [Specify – Cardio/ Resp./lab /other])
  •  Aftercare; Follow-up; Donor; Counseling and Obstetrical services.
    – Specify as applicable.

Ch 21: Factors Influencing Health

Notes

ICD-9-CM V-codes are now Z- codes, which may be used as primary or secondary.
May be used in any healthcare setting.

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