Ob-Gyn Coding Alert

Learn how you’ll report intrahepatic cholestasis of pregnancy as of October 1.

Although you may think a handful of new intrahepatic cholestasis of pregnancy (ICP) codes may mean that this year’s ICD-10-CM update doesn’t offer you much to learn, you may be missing out on the subtle revisions to the notes — which could mean the difference between reimbursement and denial.

Background: The U.S. Centers for Disease Control and Prevention (CDC) issued updates to the ICD-10-CM code set in July, making more than 400 changes to the diagnosis code set. Although these changes don’t take effect until Oct. 1, 2023, ob-gyn practices should get to know the new changes as soon as possible.

Learn New Codes for Intrahepatic Cholestasis of Pregnancy

If your ob-gyn sees a patient with ICP, then you will have new ICD-10-CM codes at your disposal.

According to the ICD-10 Committee Meeting Notes, ICP is a “pregnancy-specific disorder where bile acid transport in the liver is altered. This leads to a build-up of bile acid in both the maternal circulation as well as the fetal amniotic fluid.” This is a rare condition, affecting about 0.5 percent of pregnancies in the United States, and resolves with the birth of the baby, the Notes continues.

Both mother and fetus carry risks. Your ob-gyn will most likely monitor the mother for pre-eclampsia and gestational diabetes. When a patient has ICP, the baby could also be at risk for preterm birth, increased respiratory distress after birth, meconium staining of amniotic fluid, and stillbirth.

The new ICD-10-CM codes are as follows:

• O26.64- (Intrahepatic cholestasis of pregnancy)
• O26.641 (Intrahepatic cholestasis of pregnancy, first trimester)
• O26.642 (Intrahepatic cholestasis of pregnancy, second trimester)
• O26.643 (Intrahepatic cholestasis of pregnancy, third trimester)
• O26.649 (Intrahepatic cholestasis of pregnancy, unspecified trimester)

Dig Into These 2 Gynecological Coding Details

You will see the first note for both A40 (Streptococcal sepsis) and A41 (Other sepsis) has been revised. The language changed from “streptococcal sepsis following abortion or ectopic or molar pregnancy (O03-O07, O08.0)” to “streptococcal sepsis following abortion or ectopic or molar pregnancy (O03.37, O03.87, O04.87, O07.37, O08.82).”

How this is different: “So they are getting specific about which codes to code first instead of a spread of codes,” says Melanie Witt, RN, MA, an independent coding expert based in Guadalupita, New Mexico..

Also, underneath N81.6 (Rectocele), you’ll see another revision under the Notes. You’ll add “Excludes1: rectocele with prolapse with uterus (N81.2-N81.4),” which is a change from being an Exclude2 note.

How this is different: This means, before October 1, “you could have coded both N81.6 and N81.2-N81.4; but as of October 1, you cannot report both N81.6 and N81.2-N81.4,” Witt says.

Remember: According to the ICD-10-CM Official Guidelines, section I.A.12.a, Excludes1 is a “pure excludes note,” which means the listed code should never be used at the same time as the code listed above the Excludes1 instruction. Another way of interpreting the rule is that the two conditions cannot occur together. On the other hand, according to the ICD-10-CM Official Guidelines, section I.A.12.b, an Excludes2 note represents “not included here.” This means that the condition is not a part of the condition represented by the initial diagnosis code, “but a patient may have both conditions at the same time.” In short, Excludes1 means the two codes may never be used together, while Excludes2 allows two or more codes to be used together, when appropriate.

Not a surprise: “Every year since the adoption of ICD-10-CM, there have been modifications to the Excludes1 and Excludes2 notes, as the folks in charge try to align their coding rules with coding realities,” says Sheri Poe Bernard, CPC, CRC, CDEO, CCS-P, author of the AMA book Risk Adjustment Documentation and Coding. So, whether you still code manually, or use an electronic medical record (EMR), you will need to ensure your code choices incorporate the Excludes note revisions found in the ICD-10-CM updates when they take effect.

Obstetric Notes Also Get 9 Different Revisions

1. Under the initial “use additional” note at the beginning of Chapter 15, “they have revised the statement about using category Z3A codes,” Witt says. It currently specifies “use additional code from category Z3A, Weeks of gestation, to identify the specific week of the pregnancy, if known.” As of October 1, the note will say “use additional code, if applicable, from category Z3A, Weeks of gestation, to identify the specific week of the pregnancy, if known.”

How this is different: The change pertains to the “if applicable” verbiage and now matches ICD-10-CM Guidelines, which indicate that Z3A codes would not be used with abortive pregnancies, elective abortion, or postpartum conditions.

2. You’ll also see a revision involving the Excludes note for code O04 (Complications following (induced) termination of pregnancy) from an Excludes1 to an Excludes2 note. The new note states:

Excludes2: encounter for elective termination of pregnancy, uncomplicated (Z33.2)

failed attempted termination of pregnancy (O07.-)

How this is different: You will now be able to report both an O04 code with Z33.2 or an O07.- code, should the documentation warrant it.