Vaginal deliveries are the most common type of obstetric delivery, but there can be great variety among the diagnoses and procedures involved with these deliveries. Being familiar with pertinent ICD-10-CM and ICD-10-PCS coding guidelines and knowing a little about what the ICD-10-PCS character values for these codes represent will go a long way in helping you make appropriate codes choices.
Coding of vaginal deliveries requires a minimum of 3 codes; a principal diagnosis code, an outcome of delivery code and a weeks of gestation code. Fortunately, there are guidelines and notes to provide direction in properly assigning these codes.
For delivery admissions, the principal diagnosis is the condition that prompted the admission. If multiple conditions prompted the admission, the condition most related to the delivery is the principal diagnosis (ICD-10-CM Coding Guideline I.C.15.b.4).
Code O80 Encounter for full term uncomplicated delivery is assigned as the principal diagnosis for delivery admissions that meet the following criteria (ICD-10-CM Coding Guideline I.C.15.n):
- Vaginal delivery at full term
- No accompanying instrumentation (episiotomy is ok)
- Single, healthy infant
- No unresolved antepartum complications
- No complications of labor or delivery
- No postpartum complications during the delivery admission
Outcome of Delivery (Z37.-)
An outcome of delivery code from category Z37 should be assigned for every delivery admission and only on the delivery admission, never for subsequent admissions. These codes are only for use on the mother’s record (ICD-10-CM Coding Guideline I.C.15.b.5). It is appropriate to assign an outcome of delivery code for admissions when elective termination of pregnancy results in a liveborn fetus (ICD-10-CM Coding Guideline I.C.15.q) and code Z37.0 Single live birth, is the only outcome of delivery code for use with O80 (ICD-10-CM Coding Guideline I.C.15.n.3).
Weeks of Gestation
The notes at the beginning of Chapter 15 Pregnancy, Childbirth and the Puerperium indicate that in addition to the Chapter 15 codes, the coder should assign a code from category Z3A, Weeks of gestation, to identify the specific week of the pregnancy, if known.
The guidelines provide further direction, indicating that weeks of gestation codes are not assigned for encounters for (ICD-10-CM Coding Guidelines I.C.21.c.11):
- Pregnancies with abortive outcomes
- Elective termination of pregnancy
- Postpartum conditions
The guidelines also provide clarity around which week of gestation code to choose when coding for encounters that span more than one gestational week. For those admissions, assign the weeks of gestation code based on the date of admission (ICD-10-CM Coding Guideline I.C.21.c.11).
A spontaneous delivery is a vaginal delivery that is manually assisted with no use of instrumentation such as forceps or vacuum extraction. In ICD-10-PCS, the code for this procedure will be the same every time, 10E0XZZ. Looking at the table below you can see that there is only one option for the value for each character in the code.
This procedure is reported with a code from the Obstetrics section of ICD-10-PCS because it is a procedure performed on the fetus, which is considered a product of conception (see ICD-10-PCS coding guideline C1). The root operation for a spontaneous delivery is Delivery and the body part is Products of Conception. A delivery that only requires the physician to manually assist a spontaneous process takes place entirely outside the patient’s body, so the approach is External.
It’s interesting to note that if code O80 Normal delivery is assigned the principal dx for a delivery admission, code 10E0XZZ is this is the only appropriate ICD-10-PCS code to accompany that diagnosis.
An assisted vaginal delivery is one that is accomplished with the assistance of instrumentation such as forceps or vacuum extraction. Just like a spontaneous delivery, this procedure is reported with a code from the Obstetrics section of ICD-10-PCS because it is a procedure performed on the fetus, which is considered a product of conception (see ICD-10-PCS coding guideline C1).
Because the fetus is not passing from the mother spontaneously, but is rather being pulled out of the genital canal by force, the root operation for this procedure is Extraction. The body part is Products of Conception. Do not choose the body part value for retained or ectopic products of conception as those don’t apply here. The approach for a vaginal delivery is always Via Natural or Artificial Opening. The value of the Qualifier character will differ depending on the type of instrumentation used to deliver the fetus. If forceps are used, you must decipher from the documentation the type of forceps used (low, mid, high) to assign a correct code.
When an episiotomy is performed in conjunction with a vaginal delivery, a separate code is assigned for the episiotomy. Note that performance of an episiotomy does not indicate the presence of a complication and therefore does not preclude assignment of code O80 with an episiotomy procedure code.
As with the code for spontaneous vaginal delivery, the ICD-10-PCS code for episiotomies will be the same every time, 0W8NXZZ. Looking at the table below you can see that there is only one option for the value for each character in the code.
Episiotomies are reported with a code from the Medical and Surgical section of ICD-10-PCS because this procedure is performed on the pregnant female (see ICD-10-PCS coding guideline C1). Note that the body system is Anatomical Regions, General. You might be tempted to try to find a code under the body system Female Reproductive System, but doing so will not give you the options needed to build a correct code. The root operation is Division because the perineum is being transected to allow more room for passage of the fetus during delivery. The body part is Perineum and the approach is External.
Being familiar with and following the ICD-10-CM and ICD-10-PCS coding guidelines is always a good practice when assigning codes from these classifications, and the assignment of codes for vaginal deliveries is no exception.
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