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Medical Coding News Archives

Specialty Focus: OB/GYN—To report trimester or not?

 
December 1, 2015:

ICD-10-CM guideline 1.C.15.a.3 notes that many of the codes in chapter 15 have a final character that indicates the trimester the care is rendered. But reporting the trimester is not automatic. For example, the majority of missed abortions occur in the first trimester or the early weeks of the second trimester. This guideline also states that if the trimester is not part of the code, “it is because the condition always occurs in a specific trimester, or the concept of trimester of pregnancy is not applicable.”

Have a look at this case study from the ICD-10-CM Coding Workbook for OB/GYN which illustrates this issue.

A 26-year-old gravida 1, para 0 was approximately 9 weeks’ gestation. She presents today for evaluation with bleeding and passing of tissue and clots. Exam in the office confirms the cervix was dilated with tissue and blood passing from the cervical os. The patient had experienced an incomplete spontaneous abortion. She was emergently scheduled for suction dilatation and evacuation.

The diagnosis codes for this case are the following. Note that the trimester character is not reported.

    O02.1 Missed abortion

    Z3A.09 9 weeks gestation of pregnancy

Earn 10 CEUs from AAPC with the2016 ICD-10-CM Coding Workbook for OB/GYN. Just pass the online exam with a score of 75% or better. CEUs are also available for the each of the ICD-10-CM Coding Workbooks.

 

 
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