Ob-Gyn Coding Alert

Here’s what diagnoses to use for confirmed case ultrasounds.

According to the World Health Organization, the Zika virus disease is caused by a virus transmitted by Aedes mosquitoes. People with Zika virus disease usually have symptoms that can include mild fever, skin rashes, conjunctivitis, muscle and joint pain, malaise or headache. However, you may be wondering how to use ICD-10 codes should a pregnant patient arrive in your office.

A subscriber asked, “We have the coding for an ob patient who has contracted the Zika virus, but need guidance on for OB patients who may have been exposed while traveling. What should we do for exposure?”

Read on to learn what you should report.

Pay Attention to Your Primary Code

Per AHIMA, you should code the virus as A92.8 (Other specified mosquito-borne viral fevers). If she is pregnant, the primary code would be O98.51- (Other viral diseases complicating pregnancy...) with the sixth character identifying trimester.

If you are screening for a pregnant patient who was possibly exposed when traveling (no symptoms and no known cases she came into contact with other than being in the area), you report one of the screening codes listed below to test for the virus. 

Watch out: This is not antenatal screening, so Z36 (Encounter for antenatal screening of mother) would not apply. Also, when doing just screening, you should not report an ob complication code. You could, however opt to include as a secondary diagnosis, the code for incidental pregnancy, Z33.1 (Pregnant state, incidental). You’ll use the complication codes should she test positive for the virus. 

How to Reflect Sexual Transmission

As news outlets report, the Zika virus can be sexually transmitted (but you would have to know the patient had sex with a person who has the virus or that partner had sex with a person who had the virus of course), you could report this screening for the virus with either:

• Z11.3, Encounter for screening for infections with a predominantly sexual mode of transmission or
• Z11.59, Encounter for screening for other viral diseases.

If the patient was exposed to a person who had the virus, you can report Z20.828 (Contact with and (suspected) exposure to other viral communicable diseases). The ICD-10 rule for use of Z20 codes is: “Category Z20 indicates contact with, and suspected exposure to, communicable diseases. These codes are for patients who do not show any sign or symptom of a disease but are suspected to have been exposed to it by close personal contact with an infected individual or are in an area where a disease is epidemic.”

Must-have:  Your provider would have to document this information at the time of the visit, including the epidemic area she visited.

Justify Ultrasounds With These Dx

Finally, if your physician is doing ultrasounds to determine if the fetus was affected for confirmed cases of the virus, you would go with

• O35.0- (Maternal care for (suspected) central nervous system malformation in fetus) or
• O35.3XX- (Maternal care for (suspected) damage to fetus from viral disease in mother).