Ob-Gyn Coding Alert

Question: My ob-gyn saw a pregnant patient who broke her toe. What diagnosis should I use? Should I choose one of the codes for complications of pregnancy?

Maine Subscriber

Answer: Your coding choice depends on what your physician has documented. The guidelines are quite clear that the ob-gyn must indicate that the condition is not complicating or affecting the pregnancy to use the fracture code and Z33.1 (Pregnant state, incidental).

If he does not include this statement in the medical record and he evaluates, treats or manages the broken toe, you have to use a code from the ob chapter as the primary diagnosis.  

The ICD-10 rules' default is that the condition is affecting the pregnancy. In that case, you should use O99.89 (Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium) and the fracture code. If the ob-gyn simply notes that the patient has a broken toe without intervention, this is not a codeable diagnosis.