Inpatient Facility Coding & Compliance Alert

For a cesarean, ICD-10-CM guidelines say to use this code as your primary dx.

Although the terminology seems cold, ICD-10-PCS says you should treat cesareans as “extractions of products of conception.” Check out this procedure note and go the extra step of applying both ICD-10-CM codes to your single procedure code.

Read Through This Inpatient Note

Inpatient admission: The patient, gravida II, para 1, was admitted at approximately 33 weeks gestation. She has mild contractions and was contracting every 7-8 minutes. An ultrasound shows twins, approximately four pounds each. I gave the patient magnesium sulfate to stop the contractions, but she continued contracting through the drug. After developing a fever with suspected chorioamnionitis, I performed a low cervical cesarean section. The umbilical cord was found to be wrapped tightly around the neck of twin 1.

Discharge diagnoses: Cesarean of liveborn twins prematurely at 33 weeks gestation. Chorioamnionitis. Umbilical cord compression.

Break Down Your ICD-10-CM Diagnoses

Here’s how you should report your diagnoses.

Important: Because the patient is at 33 weeks, she is in the third trimester, which is defined by 28 weeks through delivery.

Therefore, you should report the following obstetric codes:

• O60.14x0 — Preterm labor third trimester with preterm delivery third trimester; not applicable or unspecified
• O30.003 — Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, third trimester
• O41.1230 — Chorioamnionitis, third trimester; not applicable or unspecified
• O69.1xx1 — Labor and delivery complicated by cord around neck, with compression; fetus 1

You would also report outcome code Z37.2 (Outcome of delivery, twins, both liveborn).

Primary diagnosis: These are numerous ICD-10-CM codes, several of which could qualify as the primary diagnosis. Refer to ICD-10-CM Guideline I.15.b.4 Selection of OB Principal Diagnosis When a Delivery Occurs. This section states:

When a delivery occurs, the principal diagnosis should correspond to the main circumstances or complication of the delivery. In cases of cesarean delivery, the selection of the principal diagnosis should be the condition established after study that was responsible for the patient’s admission. If the patient was admitted with a condition that resulted in the performance of a cesarean procedure that condition should be selected as the principal diagnosis. If the reason for the admission/encounter was unrelated to the condition resulting in the cesarean delivery, the condition related to the reason for the admission/encounter should be selected as the principal diagnosis, even if a cesarean was performed.

Therefore, you should report O60.14x0 as your primary diagnosis.

Check Your ICD-10-PCS Procedure Code

Remember, every ICD-10-PCS code has seven characters. Here’s how to break down your ICD-10-PCS selection.

• Character 1: The physician performed a cesarean, so you know that you need to refer to the ob section of your ICD-10-PCS manual. That’s “Chapter 1 Obstetrics.”
• Characters 2-3: According to ICD-10-PCS, a cesarean is an “extraction.” Therefore, you should look at the table for “Pregnancy, Extraction” which is the table for 10D.
  
  
  
• Character 4: Your next digit should be “0” for “Products of Conception.”
• Character 5: Your next code is “0” for “Open.” This specifies the cesarean section.
• Character 6: Then, you should report “Z,” because the physician did not use a device.
• Character 7: Finally, your last selection is “1” for “Low cervical.” The physician specified a low cervical cesarean section in the documentation.

What to report: Put all these codes together, and you’ll have 10D00Z1.