OBGYN
- Ch 2: Neoplasms C00-D48
- Ch 14: GU Kidney Disease N00-N99
- Ch 15: Obstetrics & Gynecology O00-O99
- Ch 16: Perinatal P00-P96
- Ch 21: Factors Influencing Health Z00-Z99
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.
Additional Resources
Coding for ICD-10-CM: More of the Basics MLN Connects Video
For more information contact the AMA.