ICD 10 Coding Guideline
The primary diagnosis for an obstetric admission is always coded from this chapter of ICD-10-CM.
What is Chapter 15 (Pregnancy, Childbirth, and the Puerperium)?
Postpartum hemorrhage is defined as blood loss exceeding this amount after a vaginal delivery.
What is 500 mL?
This term must be documented to distinguish gestational hypertension from chronic hypertension.
What is “new-onset hypertension after 20 weeks of pregnancy”?
This CDC-defined metric tracks obstetric patients experiencing life-threatening complications during delivery.
What is Severe Maternal Morbidity (SMM)?
This key distinction must be documented when a provider notes “abortion” in the record.
What is spontaneous vs. elective vs. missed vs. septic abortion?
If a patient has a pre-existing condition that complicates pregnancy, this term is used to classify the diagnosis.
What is an antepartum complication?
This infection, commonly tested for at 35-37 weeks, can cause neonatal sepsis if not treated before delivery.
What is Group B Streptococcus (GBS)?
If a provider documents alcohol use in pregnancy, CDI specialists should ensure they specify whether it is this level of consumption.
What is occasional use vs. alcohol dependence?
One of the most common reasons for postpartum readmission is this life-threatening condition, often linked to retained products of conception or uterine atony.
What is postpartum hemorrhage (PPH)?
Chronic maternal smoking during pregnancy increases the risk of this obstetric complication.
What is placental abruption?
Postpartum depression is documented in ICD-10-CM using codes from this category.
What is F53 (Mental and behavioral disorders associated with the puerperium)?
This intra-amniotic infection, often associated with prolonged labor, requires antibiotic treatment.
What is chorioamnionitis?
Documentation of cesarean section should include this clinical justification to avoid unspecified coding
What is the reason for C-section (e.g., fetal distress, failure to progress, breech presentation)?
These two life-threatening conditions are leading contributors to SMM and require timely documentation for accurate reporting.
What are eclampsia and obstetric hemorrhage?
To support correct coding of gestational diabetes, the documentation should specify if it is controlled by these methods.
What are diet (A1) or insulin/medication (A2)?
In ICD-10-CM, maternal drug dependence during pregnancy is coded from this category.
What is O99.32 (Maternal use of drugs affecting fetus or newborn)?
This rare but severe psychiatric disorder occurs postpartum and may involve delusions or hallucinations.
What is puerperal psychosis?
If a patient has premature rupture of membranes (PROM), CDI specialists should ensure the provider documents whether it is this additional condition.
What is prolonged PROM (lasting more than 18 hours)?
Cesarean delivery rates contribute to hospital rankings in this major national perinatal safety accreditation program
What is the Joint Commission’s Perinatal Core Measure Set (PC-02)?
When documenting hyperemesis gravidarum, providers should specify if the patient also has this metabolic complication.
What is dehydration?
The coding guideline states that postpartum complications can be reported for this period after delivery.
What is six weeks (or the puerperium)?
This neonatal condition results from in-utero opioid exposure and requires specific documentation for accurate coding.
What is neonatal abstinence syndrome (NAS)?
A patient with severe postpartum hemorrhage should have documentation specifying this key detail for CDI accuracy.
What is the cause (e.g., uterine atony, retained placenta, coagulopathy)?
This national hospital quality program monitors 30-day readmission rates as a key performance measure for OB patients.
What is the Hospital Readmissions Reduction Program (HRRP)?
Early elective deliveries before 39 weeks are discouraged due to increased risks of this neonatal complication.
What is respiratory distress syndrome (RDS)?