Discharge Summary

This is a healthy 29-year-old gravida 2 para 1 here for delivery of her baby. The pregnancy has been uncomplicated to date. She is 39 weeks, 2 days.

During delivery depressed fetal heart tones occurred and the decision to use forceps for delivery is made. 

A midline episiotomy is created with application of the low forceps for a vaginal delivery. A single liveborn infant is delivered without further complication. The episiotomy was subsequently repaired by an episiorrhaphy.

ANSWERS

Diagnoses:

1. O76 Abnormality in fetal heart rate and rhythm complicating labor and delivery
2. Z37.0 Outcome of delivery, single, liveborn
3. Z3A.39 Pregnancy, weeks of gestation, 39 weeks

Rationale:

The principal diagnosis for this case is O76. ICD-10-CM Coding Guideline I.C.15.b.4 states that when a delivery occurs, the principal diagnosis should correspond to the main circumstances or complication of the delivery.

The secondary diagnosis code of Z37.0 indicates that the outcome of the delivery was a single liveborn infant. ICD-10-CM Coding Guideline I.15.b.5 states that a code from category Z37, Outcome of Delivery, should be included on every maternal record when a delivery has occurred. These codes are not to be used on subsequent records or on the newborn record.

In the Tabular at the beginning of Chapter 15, the following note appears: “Use additional code from category Z3A, Weeks of gestation, to identify specific week of pregnancy.”

Procedures:

10D07Z3 Extraction, Products of Conception, Low Forceps (10D07Z3) Delivery, Forceps, see Extraction, Products of Conception (10D0)

0W8NXZZ Division, Perineum, Female (0W8NXZZ) Episiotomy, see Division, Perineum, Female (0W8N)

Rationale:

Procedures: ICD-10-PCS Coding Guideline C.1 states that the Obstetrics section includes only the procedures performed on the products of conception. Procedures performed on the pregnant female other than the products of conception are coded to a root operation in the Medical and Surgical section.

Products of conception refer to all components of pregnancy, including fetus, embryo, amnion, umbilical cord, and placenta. There is no differentiation of the products of conception based on gestational age. Therefore, since the low forceps delivery is performed on the fetus, it is coded to the Obstetrics section of ICD-10-PCS.

The use of the low forceps to deliver the fetus is coded to the root operation Extraction. Extraction is defined as the pulling or stripping out of all or a portion of a body part. In this case, the low forceps are used to pull out the body part (products of conception).

The episiotomy is coded to the Medical and Surgical section because it is performed on the pregnant female. The code for episiotomy is 0W8NXZZ. The main term Episiotomy in the Alphabetic Index refers the coding professional to “see Division, Perineum, Female (0W8N).” The root operation Division is coded when the objective of the procedure is to cut into, transect, or otherwise separate all or a portion of a body part.

The episiorrhaphy is not coded separately, per ICD-10-PCS Guideline B3.1b which states that procedural steps necessary to reach the operative site and close the operative site are not coded separately.