ICD-10-CM pregnancy, childbirth, and puerperium

1. Week 6
HIT205
PROFESSOR

2. Coding Guidelines
Keep in mind all sections of the ICD10CM coding guidelines while reviewing code assignments.
Section I
◦ A: Coding Conventions
◦ B: General Guidelines
◦ C: Chapter specific guidelines
Section II: Selection of Principal Diagnosis
Section III: Reporting Additional Diagnoses
Section IV: Diagnostic- Coding and Reporting Guidelines for Outpatient Services
Some guidelines are determined based upon the site of the encounter

3. Case 1 – Pregnancy, Childbirth &
Puerperium
Physician Office Note of 2/04/XX
WEIGHT: 150 pounds. This is a weight gain of 7 pounds since last visit 3 weeks ago. Blood
pressure: 140/80. Lab: Urinalysis reveals protein present.
Patient is complaining of increased headaches and dizziness.
VAGINAL EXAM: Normal
HEENT: Face appears swollen.
EXTREMITIES: Edema of hands and feet
Patient symptoms indicate mild pre-eclampsia during the 39th week. Patient advised to decrease
salt intake and to follow up in 2 weeks.
What are the ICD10CM code assignments?

4. Case 2 – Pregnancy, Childbirth &
Puerperium
Discharge Summary
ADMISSION DATE: 5/6/XX, Discharge date: 5/8/XX
HISTORY:
This patient is gravida 2, para 1 and was seen in my office for all of her prenatal visits. Currently at 39 gestational
weeks. Her prenatal course was uneventful. She was admitted with a history of contractions every 3 to 5 minutes.
Cervix was 100% effaced and 9 cm dilated.
HOSPITAL COURSE:
At the time of admission, patient received IV and was placed on a fetal monitor. Her water broke at 2 a.m. After 3
hours the patient delivered a baby boy with APGAR scores of 8 at 1 minute and 10 at 5 minutes. Postpartum care
was uneventful. The patient was discharged 2 days later.
INSTRUCTIONS TO PATIENT: Diet as tolerated. Tylenol every 4 hours for pain. She is to follow up in my office in 2
weeks.
What are the ICD10CM code assignments?

5. Case 3 – Pregnancy, Childbirth &
Puerperium
Physician Office Note
This patient presents today in the 38th week of her pregnancy. She
complains of increased fatigue over the last month, edema of both legs,
shortness of breath, and difficulty breathing when lying down.
I have monitored her closely for the last 2 months. Last week I sent her
for an EKG, chest x-ray, and coronary angiography. Today I am reviewing
the results with her.
EXAM: Reveals an obese, gravida 1, para 0, 29-year-old woman.
HEENT: Normocephalic, palpebral conjunctiva, pinkish, PERRLA
NECK: Supple. No mass noted.
HEART: Tachycardia present. Slight murmur.
LUNGS: There is congestion in both lungs.
ABDOMEN: Protuberant, soft, and nontender. Liver and spleen not
palpable. Uterus enlarged to gestational size. Fetal heart tones are
noted to be normal.
PELVIC: External genitalia, normal. Vagina, clear. Membranes, intact.
EXTREMITIES: There is edema in both legs.
Review of diagnostic testing: EKG, chest x-ray, and coronary
angiography results support a diagnosis of peripartum cardiomyopathy.
I discussed with the patient the need for medications to improve her
heart function, decrease edema, and prevent the formation of blood
clots that can occur with the diagnosis of peripartum cardiomyopathy.
Medications were ordered as per medication record.
INSTRUCTIONS TO PATIENT: I explained to the patient the need to take
her medications as prescribed.
She is to follow up with me in 5 days.
What are the ICD10CM code assignments?

6. Case 5 – Pregnancy, Childbirth &
Puerperium
Physician Office Visit
This 27-year-old female, who is 12 weeks pregnant, is experiencing increased thirst, increased
urination, increased fatigue, and bouts of nausea. An in-office blood sugar reading was 245, so a
glucose tolerance test was ordered. The results confirmed gestational diabetes. Insulin is not
necessary at this time.
What are the ICD10CM code assignments?

7. Case 6 – Pregnancy, Childbirth &
Puerperium
Physician Office Visit
This 25-year-old patient is being seen today for follow-up care. Gestational diabetes is controlled
by diet. The pregnancy is progressing well. Vital signs are within normal limits. The fetal
heartbeat was normal. She is to follow up with me in 3 weeks. This is the 30th week of
pregnancy.
What are the ICD10CM code assignments?

8. Case 7 – Pregnancy, Childbirth &
Puerperium
Physician Office Visit
This 25-year-old, 29-weeks-pregnant patient presents to the office today stating that she is
experiencing urinary urgency, dysuria, and low back pain. Urinalysis and C/S confirmed UTI due
to E. coli. A prescription for antibiotics was written.
What are the ICD10CM code assignments?

9. Case 8 – Pregnancy, Childbirth &
Puerperium
Discharge Summary
This 13-weeks-pregnant patient is being discharged today following a 7-day length of stay for
severe hyperemesis with electrolyte imbalance. She was given IV prenatal vitamin supplement
and was NPO. After 4 days the vomiting subsided. She is now able to tolerate small amounts of
food. She is discharged home at this time with instructions to call me if the vomiting persists
throughout an entire day.
What are the ICD10CM code assignments?

10. Case 10 – Pregnancy, Childbirth &
Puerperium
Office Visit Note
This patient returns to my office today following delivery of a female infant 2 weeks ago. She
states that she is having bilateral breast pain that is increasing in intensity for the last 4 days.
Upon exam both breasts appear red and warm to the touch, confirming puerperal mastitis. The
patient is very anxious about this and I informed the patient that this is nothing to be alarmed
about. The patient was instructed to apply a heated compress to both breasts and to take Tylenol
for the discomfort and to wear a firm supporting bra to increase her comfort.
She was instructed to return to me if the symptoms increase.
What is the ICD10CM code assignment?

11. Case 3 – Conditions Originating in the
Perinatal Period
Discharge Summary
The patient was discharged in stable condition on 1/20/XX. She is to continue on breast milk and
can be supplemented with Similac with iron.
This patient is the product of a full-term gestation. The APGARs were 9 and 10. Birth weight was
6 pounds 10 ounces. Physical examination shortly after birth was negative. The infant's
temperature was elevated, and urinalysis revealed a urinary tract infection. The plan was to
observe the patient. Antibiotic therapy was started.
She had no difficulty nursing and ate well while she was in the hospital. She had no problems
with her bowel movements. On the day of discharge, the patient's weight was down 3 ounces
from birth. She will be seen in my office in 7 days.
What are the ICD10CM code assignments?

12. Case 4 – Conditions Originating in the
Perinatal Period
Hospital Visit Note
The patient is a female, born 36 hours ago and now experiencing convulsions. The product of a
normal delivery with birth weight of 7 pounds 2 ounces. Her vital signs are normal at this time.
The nursing staff contacted this physician immediately upon noting the convulsions, which they
said lasted several seconds. An EEG and ECG have been ordered, along with a complete blood
workup. The baby will be monitored closely until all test results are back.
What is the ICD10CM code assignment?

13. Case 5 – Conditions Originating in the
Perinatal Period
Hospital Visit Note
The patient is a newborn infant male, born 2 hours ago to a mother who was
experiencing severe hypertension prior to her pregnancy. The mother was being
monitored closely for this condition during her current pregnancy because she had
difficulty during her last one. It appears now that this baby boy is experiencing some
respiratory distress due to the maternal hypertension. Pulse ox reading was 70, and his
respirations were elevated. His vital signs at this time are all within normal limits since we
started the oxygen. His pulse ox reading is now at 98. He will be monitored until such
time as there is no need for the oxygen and his vital signs remain normal.
What are the ICD10CM code assignments?

14. Case 6 – Conditions Originating in the
Perinatal Period
Discharge Note
This 15-day-old infant was born in the hospital and discharged. Ten days after discharge she
developed a high fever and she was seen in my office. Diagnostic testing indicated sepsis due to
group B streptococcus.
She is stable at this time and she is being discharged home.
What is the ICD10CM code assignment?

15. Case 7 – Conditions Originating in the
Perinatal Period
Discharge Note
This 7-pound, 2-ounce female infant was born 4 days ago and there were no complications during
the delivery. The following day the child appeared jaundice and a diagnosis of hyperbilirubinemia
was made. She was given phototherapy. She is now stabilized and she is being discharged with no
other complications.
What are the ICD10CM code assignments?

16. Case 8 – Conditions Originating in the
Perinatal Period
Physician Office Note
This 12-day-old infant presents to the office today with numerous pustules that have a yellow
crust over the lesions. The lesions are on the infant's face and hands consistent with neonatal
pyoderma. I instructed the mother to bath the child twice a day and to apply an antibiotic
ointment. If the skin does not clear within 1 week they should return to the office.
What is the ICD10CM code assignment?

17. Case 9 – Conditions Originating in the
Perinatal Period
Discharge Note
This 4-day-old infant is being discharged today following a normal delivery. The child did
experience noninfectious diarrhea for the last 2 days that has now stabilized. I instructed the
mother to supplement her breast feeding with Pedialyte and to call me if the diarrhea increases.
What are the ICD10CM code assignments?