Pregnancy Coding Guidelines
When coding an encounter for a pregnant woman with any disease/condition/complication, what (type of) code should be sequenced FIRST?
A code from Chapter 15 (O code)
A pregnant woman is seen but no weeks of gestation are specified. How should the coder report this?
Z3A.00
Codes from Chapter 19 require a 7th digit to indicate:
Episode of care (initial, subsequent, sequelae)
A woman trips and falls during some intense worship at her church and recieves a contusion to her forehead. What place of injury code should be assigned for this encounter?
Y92.22
Define the medical term mastectomy.
Removal of the breast
Codes from Chapter 15 always require two codes. What (type of) code is always sequenced last?
Weeks of gestation (Z3A.XX)
A pregnant woman is diagnosed with gestational diabetes, controlled by insulin, at 22 weeks gestation.
O24.414, Z3A.22
Up to 5 codes can be assigned for a single injury. Name 3 of the (types of) codes that could be reported if documentation exists.
Code for the injury, external cause of injury, place of injury, activity during the injury, work status during the injury
A child falls off a playground swing and is diagnosed with a contusion of the left knee, initial encounter. What code should be reported for the injury only?
S80.02XA
Define the medical term gynecologist.
Specialist in the study of women
Codes from Chapter 15 most often require a final character to indicate:
Trimester of pregnancy (1, 2, 3, or 9)
A woman presents to her physician with a sore throat. She is 29 weeks pregnant. The physician documents acute pharyngitis in pregnancy.
O99.513, J02.9, Z3A.29
A provider documents both a fracture and contusion of the lower leg. Which (or both) should be coded? If multiple codes are reported, how should they be sequenced?
Only the fracture
A patient is seen for follow-up of a closed fracture of the shaft of the right tibia. The provider documents that the fracture is healing normally.
S82.201D
Define the medical term postnatal.
Pertaining to after birth.
When coding for gestational diabetes, an additional character is required to indicate:
Type of control (diet, insulin, oral hypoglycemics, unspecified)
A 30 year old (G2P1) presents for supervision of an uncomplicated pregnancy.
Z34.80, Z3A.00
A provider documents a third degree burn of the abdominal area, as well as a smaller area of first degree burn of that area as well. Which (or both) should be coded? If multiple codes are reported, how should they be sequenced?
Third degree
A patient presents to the urgent care after cutting their right index finger with a kitchen knife while preparing food. The provider documents a laceration of the right index finger.
S61.210A, W26.0XXA
Define the medical term endometriosis.
Condition of inside the uterus.
When coding an encounter that resulted in delivery, three codes are required: The first, the reason/complication of delivery OR Encounter for full-term, uncomplicated delivery. What 2 other (types of) codes are required for these encounter?
Outcome of delivery (Z37.X) and Weeks of gestation (Z3A.XX)
A woman presents in labor at 40 weeks gestationand delivers a healthy, full-term, single infant via vaginal delivery.
O80, Z37.0, Z3A.40
A provider documents a first degree burn of the left hand, a third degree burn of the left upper-arm, and a second degree burn of the shoulder area. Which (or all) codes should be reported and if multiple codes are reported, how should they be sequenced?
1. Third degree left upper arm
2. Second degree shoulder area
3. First degree left hand
A man intentionally ingests a large quantity of ibuprofen and is brought to the ER. The provider diagnoses poisoning by ibuprofen, intentional self-harm, initial encounter, along with nausea and dizziness.
T39.312A, R11.0, R42
Define the medical term tocometry.
Process of measuring labor