Question

• Assign the correct ICD-10-AM/ACHI codes to the following:

1- This23-year-old female was admitted at 38 weeks gestation for induction of labor due to mild pre-eclampsia. The patient failed to dilate during medical induction. The decision was made to perform a cesarean section due to failed induction. The fetus was found to be in compound position.

2- Pregnancy delivered, single liveborn, vaginal delivery following prolonged first stage of labor, 38 weeks of gestation.

3- The patient is seen in the ED for the initial visit for a sprained left wrist; the doctor documents that the patient is pregnant, but specifically states the pregnancy is incidental to the encounter.

4- The patient presented through the ED with severe abdominal pain, amenorrhea. Serum human chorionic gonadotropin (hCG) was lower than normal. There were also endometrial and uterine changes. Patient diagnosed with right tubal pregnancy. A laparoscopic removal of tubal pregnancy was performed.

5- The patient is a 32-year-old woman in her 26th week of pregnancy who is seen in her OB’s office for continued monitoring of her mild pre-eclampsia. The patient did not have hypertension prior to this pregnancy.

6- The 28-year-old female was seen in the office of her primary care physician for purposes of pregnancy test as she missed her last menstrual period. The patient was told the pregnancy test was negative, and she was given an appointment for the following week to investigate the reasons for missed period.

Answer 1

1.ICD-9 Chapter 11 guidelines for coding delivery say "...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." Based on this, I would use 642.41 Mild or unspecified pre-eclampsia, with delivery; then code 661.03 Primary uterine inertia (failure of cervical dilation), etc. after.

2. 080 (delivery) (child birth) labor, normal Z3A.38 pregnancy, single uterine 38 weeks of gestation,Z37.0 outcome of delivery single, liveborn.ICD-10-CM

3.If a pregnant patient with a nonobstetric injury/poisoning meets the criteria for a pregnancy complication, but there is no condition that qualifies for assignment of a code from Chapter 15, assign a code from Z34 as additional diagnosis.

4. ICD-10CM ,000.1O Tubal pregnancy without intrauterine pregnancy.

5.Mild or unspecified preeclampsia without mention of preexisting hypertension is classified to ICD-9-CM code 642.41. Severe preeclampsia without mention of preexisting hypertension is assigned to code 642.51.

6. ICD-10-CM code N92.5 used to specify a medical diagnosis of other specified irregular periods.