Tip #1: Document the specific trimester. Many of the codes in Chapter 15 of the ICD-10-CM Manual require coders to report the specific trimester of the patient’s pregnancy. For example, ICD-10-CM code O09.01 denotes supervision of pregnancy with history of infertility, first trimester. ICD-10-CM code O60.02 denotes preterm labor without delivery, second trimester.
Trimesters are counted from the first day of the last menstrual period and are defined as follows:
1st trimester: Fewer than 14 weeks 0 days
2nd trimester: 14 weeks 0 days to fewer than 28 weeks 0 days
3rd trimester: 28 weeks 0 days until delivery
Physicians can also simply document the specific number of weeks and days (rather than the trimester). Even this information is helpful because coders can calculate the trimester themselves. What physicians don’t want to do is force coders to report an unspecified trimester. This reflects poorly on the physician and his or her attention to detail and clinical care.
Tip #2: Be careful when reporting an annual GYN exam. In ICD-10-CM, the code for an annual GYN exam is not included in Chapter 15. Instead, it’s located in Chapter 21. Code Z01.4- denotes an encounter for a routine GYN exam, including the following:
Encounter for general GYN exam with or without cervical smear
Encounter for GYN exam (general) (routine), not otherwise specified
Encounter for pelvic exam (annual) (periodic)
Physicians must document whether the exam is with or without abnormal findings, as this affects code assignment. Physicians can bill an E/M code in conjunction with the appropriate ICD-10-CM code for this visit; however, only the lab can bill for the cervical smear test itself.
Tip #3: Document the cause of pelvic pain, if known. As in ICD-9-CM, if OB/GYN specialists can identify the cause of any abdominal and pelvic pain associated with menstruation, they should document this information. Causes of pain include—but aren’t limited to—adhesions, a history of endometriosis, cystic ovaries, or menorrhagia. It’s important to paint the most comprehensive picture of the patient’s clinical presentation so coders can capture all of the appropriate codes in addition to the code for pelvic and abdominal pain (ICD-10-CM code I10.-).
Tip #4: Pay attention to detail when documenting migraines. When a patient presents complaining of chronic migraines related to menstrual cramps, be sure to specify that the patient has menstrual migraines. ICD-10-CM includes codes for a variety of migraines, including those that are neurologic, abdominal, and ophthalmologic based. Also specify whether the menstrual migraine (ICD-10-CM codes G43.82- and G43.83-) is intractable vs. not intractable as well as whether it is with or without status migrainosus.
Tip #5: Document the reason for any fetus viability scans performed. Is the scan performed for routine screening for viability, or are there signs and symptoms (e.g., decreased fetal movement or fetal anemia and thrombocytopenia) that indicate that the patient may have a miscarriage? This information affects code assignment.
Tip #6: Specify whether advanced maternal age (elderly primigravida) complicates a patient’s pregnancy. If a patient is over the age of 35, specify whether her advanced maternal age is a factor in the delivery, and if so, what specific problem it caused. For example, during delivery, these patients may have pre/post eclampsia, an increased likelihood of postpartum hemorrhage, or placenta accretes. During the antepartum care, they may have an increased genetic risk factor for fetal abnormalities.
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