ICD-10 Coding standards Chapters XI-XV

Question 1

How must recurrent tonsilitis be coded?

Answer 1

Recurrent tonsillitis must be coded using J03.9 Acute tonsillitis, unspecified, in the absence of information on the specific form of tonsillitis.

Question 2

How must a Wheeze due to viral infection be coded?

Answer 2

A wheeze that is either induced, caused by, or due to a viral infection must be coded using the following codes and sequencing:
B34.9 Viral infection, unspecified
R06.2 Wheezing

Question 3

How must Postprocedural pneumonia be coded?

Answer 3

Postprocedural pneumonia must be coded to the body system code classifying the pneumonia followed by a code from categories Y83-Y84.

This index trail ‘Pneumonia - resulting from a procedure’ must not be used.

Question 4

How must Influenza A/H1N1 [swine flu] be coded?

Answer 4

Influenza A/H1N1 (also known as swine flu) must be coded to category J10.- Influenza due to identified seasonal influenza virus. Fourth character assignment is dependent on whether there are any documented manifestations.

Swine flu, with no documented manifestations, must be coded to J10.1 Influenza with other respiratory manifestations, seasonal influenza virus identified.

Question 5

When can Status asthmaticus (J46.X) be assigned?

Answer 5

J46.X Status asthmaticus must only be assigned when the responsible consultant has documented a diagnosis of:

• Acute severe asthma
or
• Status asthmaticus

If the term ‘acute asthma’, is documented without mention of ‘severe’ clarification must be sought from the responsible consultant to ensure that the correct diagnosis is coded.

Question 6

DCS.X.7: Respiratory failure, not elsewhere classified (J96)

Answer 6

Respiratory failure must always be coded when the diagnosis is recorded in the medical record. When documented with another respiratory condition, the sequencing will be dependent on the main condition being treated.

The fifth character subdivisions used with this category indicate the type of failure and must always be assigned whether the type has been specified (0, 1) or not (9).

Question 7

DChS.XI.1: Constipation in Ileus or intestinal obstruction

Answer 7

Constipation is an integral part of a diagnosis of ileus and bowel obstruction and must not be coded in addition.

Question 8

How must an oesophageal web be coded?

Answer 8

The ICD-10 Alphabetical Index assumes that an oesophageal web is a congenital condition
and classifies this to Q39.4 Oesophageal web. However, an oesophageal web can be either congenital or acquired, with acquired being more common.

The following must be applied when coding oesophageal web:

• A documented diagnosis of congenital oesophageal web must be classified to Q39.4 Oesophageal web.
• A documented diagnosis of acquired oesophageal web must be classified to K22.2 Oesophageal obstruction.
• An unspecified oesophageal web (i.e. not documented as congenital or acquired)
must be classified to K22.2 Oesophageal obstruction.

Question 9

DCS.XI.2: Barrett oesophagus with low or high grade dysplasia (K22.7)

Answer 9

Barrett oesophagus has the potential to lead to cancer. Terms such as ‘low grade dysplasia’ and ‘high grade dysplasia’ are used to describe pre-cancerous forms. The correct code for Barrett oesophagus either with or without low or high grade dysplasia is K22.7 Barrett oesophagus.

Question 10

DCS.XI.3: Peptic ulcer, site unspecified (K27)

Answer 10

Peptic ulcers must only be classified to category K27.- Peptic ulcer, when information about the site of the peptic ulcer is not available. When the site of the peptic ulcer is documented, this must be coded to an ulcer of the stated site.

Question 11

DCS.XI.4: Gastritis and duodenitis (K29)

Answer 11

Code K29.9 Gastroduodenitis, unspecified must only be assigned if the patient has both K29.7 Gastritis, unspecified and K29.8 Duodenitis. If a specific type of gastritis is documented, then the code for the specific type must be assigned together with K29.8
Duodenitis.

The following codes must be assigned for Helicobacter pylori associated gastritis:
K29.6 Other gastritis (if a specific type is stated use a different code from K29.-)
B98.0 Helicobacter pylori [H. pylori] as the cause of diseases classified to
other chapters.

Question 12

DCS.XI.5: Parastomal hernia (K43.3-K43.5 and Z93)

Answer 12

A code from category Z93.- Artificial opening status must be assigned in addition to a code from K43.3-K43.5 to identify the type of stoma.

Question 13

DCS.XI.7: Rectal haemorrhage and per rectal haemorrhage (K62.5 and K92.2)

Answer 13

In classification terms there is a difference between a ‘rectal haemorrhage’ and a ‘per rectal
haemorrhage’.

Code K62.5 Haemorrhage of anus and rectum must only be assigned for an actual haemorrhage of the anus and/or rectum. It must not be assigned for haemorrhage that has occurred from elsewhere in the gastrointestinal tract that is merely exiting via the rectum, ie per rectal haemorrhage.

Code K92.2 Gastrointestinal haemorrhage, unspecified must be assigned for a haemorrhage that occurred via the rectum but is not specified as being from the actual
rectum or anus. This code must not be assigned when it is a symptom of a specific disease which has been diagnosed.

Question 14

DCS.XI.10: Haemorrhoids and perianal venous thrombosis (K64)

Answer 14

When more than one degree, stage or grade of haemorrhoid is documented in the medical
record, only the code for the highest degree, stage or grade must be assigned.

Where patients have a condition classified to codes K64.0-K64.3 and also a condition classified to codes K64.4 Residual haemorrhoidal skin tags or K64.5 Perianal venous thrombosis a code for both conditions must be assigned.

Question 15

DCS.XI.8: Alcoholic liver disease and alcoholic pancreatitis (K70, K85.2 and K86.0)

Answer 15

It must be stated that hepatitis or pancreatitis is due to alcohol use in order to assign codes in category K70.- Alcoholic liver disease and codes K85.2 Alcohol-induced acute pancreatitis or K86.0 Alcohol-induced chronic pancreatitis. If a patient has liver disease or pancreatitis not specified to be due to an infectious organism and the patient is also alcoholic it must not be assumed that the liver disease or pancreatitis is due to the alcoholism.

Alcoholic liver disease or alcoholic pancreatitis due to current misuse of, or dependence on, alcohol must be coded using the following codes and sequencing:

K70.- Alcoholic liver disease, K85.2 Alcohol-induced acute pancreatitis or
K86.0 Alcohol-induced chronic pancreatitis
F10.- Mental and behavioural disorders due to use of alcohol (fourth character assignment is dependent upon whether or not the responsible
consultant has stated that the alcoholic liver disease is due to harmful use of alcohol (F10.1) or dependence (F10.2)).

Alcoholic liver disease or alcoholic pancreatitis due to previous alcohol abuse must be coded using the following codes and sequencing:

K70.- Alcoholic liver disease, K85.2 Alcohol-induced acute pancreatitis or K86.0 Alcohol-induced chronic pancreatitis
Z86.4 Personal history of psychoactive substance abuse

Where the responsible consultant has given no information regarding current or past alcohol use/abuse and only states a type of alcoholic liver disease or alcohol induced pancreatitis, only assign a code from category K70.-, or codes K85.2 or K86.0.

Question 16

DCS.XI.9: Haemorrhage of digestive system (K92.0, K92.1 and K92.2)

Answer 16

When K92.0 Haematemesis, K92.1 Melaena or K92.2 Gastrointestinal haemorrhage, unspecified are symptoms of a specific disease which has been diagnosed, such as a malignant neoplasm or bleeding peptic ulcer, these codes must not be assigned in addition, unless they have been treated in their own right.

Question 17

DCS.XII.3 Pressure ulcer and leg ulcer with associated infection, cellulitis and gangrene

Answer 17

If the responsible consultant has not specified, the stage of the pressure ulcer or it is documented as ‘unstageable’ then the code L89.9 must be used.
For a leg ulcer/pressure ulcer with associated infection, must be coded as follows:

L89.- (fourth character depending on the state) or L97.X
L08.9
B95-B98 (if the infective agent is known)

If the infection spreads to another body system, this must also be coded in addition. Sequencing will depend on the main condition treated.

If cellulitis is documented with pressure ulcer or leg ulcer, both conditions must be coded. Sequencing will depend on the main condition treated.

When associated gangrene is present with the pressure ulcer or leg ulcer then code ro2.X must be coded in a secondary position to the ulcer code.

Question 18

When should the fifth characters at chapter XIII be assigned?

Answer 18

The fifth characters in Chapter XIII indicate the site of musculoskeletal involvement. The notes at chapter, category or code level indicate which codes can be further specified by the addition of a fifth character and the location of the fifth character code lists in the
classification.

The following must be applied when assigning fifth characters in Chapter XIII:

• Fifth characters must be used where the data is present in the medical record and where doing so adds more specific information about the site.
• In cases where the four character code is already site specific and the addition of a fifth character will not add further specific information about the site, the fifth
character is not required.
• The fifth character of ‘0’ indicates involvement of multiple sites. It should be assigned when the condition classified at the fourth character code affects more
than one site. The .0 must not be assigned for conditions only affecting bilateral sites; in these instances, the fifth character reflecting that site must be recorded.
• The ‘X’ filler code must be assigned in the fourth character position for three character codes which require assignment of a fifth character, for example M45.X6.

Question 19

DChS.XIII.2: Chronic versus current injuries of the musculoskeletal system and connective tissue

Answer 19

Old, recurrent or chronic injuries must be classified to a code in chapter XIII Current injuries must be classified to a code in chapter XIX unless directed elsewhere by the alphabetical index or tabular list.
If there is any doubt as to whether an injury is current or chronic then confirmation must be sought from the responsible consultant.

Question 20

DCS.XIII.2: Arthrosis (M15-M19)

Answer 20

Codes within range M15-M19 have fourth characters such as ‘primary and ‘secondary’ these are essential modifiers and must be present in the medical documentation for assignment. In the absence of any modifiers .9 at these categories must be used.

Polyarthrosis describes arthosis/osteoarthritis of more than one site and must be used if more than one site of arthrosis/osteoarthritis is specified. The exception to this is osteoarthritis of the spine.

Category M15 must not be used to code bilateral involvement of a single joint, this must be coded to categories M16-M19

M19 must be used to code arthrosis of any site other than hip (M16), knee (M17), first carpometacarpal joint (M18), or spine (M47)

Question 21

DCS.XIII.3: Rhabdomyolysis (M62.8, T79.5)

Answer 21

Rhabdomyolysis may result in kidney damage.

Any kidney damage due to non-traumatic rhabdomyolysis must be coded in addition
to M62.8 Other specified disorders of muscle.

Renal failure due to traumatic rhabdomyolysis must be coded to T79.5 Traumatic anuria alone.

Question 22

DCS.XIII.4: Pathological fractures in osteoporosis and neoplastic disease (M80, C00-D48† and M90.7*)

Answer 22

For a code for pathological fracture in osteoporosis, or pathological fracture resulting from neoplastic disease to be assigned it must be documented in the medical record that the fracture was due to osteoporosis or the neoplasm.

If the patient with osteoporosis or neoplastic disease has a fall resulting in a fracture and no link is stated this must be coded as a traumatic fracture with osteoporosis and neoplastic disease coded separately.

Question 23

DCS.XIII.5: Periprosthetic and peri-implant fractures (M96.6)

Answer 23

A documented diagnosis of ’periprosthetic/peri-implant fracture’ without an identified cause must be coded as follows:

-M96.6 Fracture of bone following insertion of orthopaedic implant, joint prosthesis, or bone plate

A documented diagnosis of ’traumatic periprosthetic/peri-implant fracture’ must be coded as follows:

• M96.6 Fracture of bone following insertion of orthopaedic implant, joint prosthesis, or bone plate
• Plus the relevant code from Chapter XX External causes of morbidity and mortality

Intraoperative fractures (including intraoperative periprosthetic/peri-implant fractures) occurring during the insertion, removal or revision of a prosthesis must be coded as follows:

• A code from Chapter XlX Injury, poisoning and certain other consequences of external causes (S00-T98) that classifies the fractured bone
• Y79.2 Orthopaedic devices associated with adverse incidents, prosthetic and other implants, materials and accessory devices

Question 24

What must be applied when assigning codes from category N18.- Chronic kidney disease?

Answer 24

The following must be applied when assigning codes from category N18.- Chronic kidney
disease:
• Where chronic kidney disease (CKD) and the underlying cause are documented both conditions must be coded.
• The code assigned for the stage of CKD must reflect the stage documented in the medical record. The glomerular filtration rate (GFR) (e.g. 45mL/min) or the
description of GFR change, (e.g. ‘mild decreased GFR’) must not be used by the coder to decide which stage of CKD the patient has.
• If a patient’s kidney function improves or deteriorates during the consultant episode and the stage of chronic kidney disease changes (e.g. from stage 1 to 2 or stage 2 to 1), the code reflecting the highest stage recorded in the medical record during the consultant episode must be coded (i.e. stage 2).
• N18.9 must be assigned for a diagnosis of chronic renal failure (CRF).
• When coding any condition classifiable to category N18.- Chronic kidney disease that is due to hypertension, a code from category I12.- Hypertensive renal disease (or category I13.- Hypertensive heart and renal disease if the patient also has hypertensive heart disease) must also be assigned. Sequencing is dependent on the main condition treated or investigated.
• When coding any condition classifiable to category N18.- Chronic kidney disease in a patient with hypertension that is not due to the hypertension, a code from category I12.- must not be assigned and the hypertension must be coded separately.
• Patients with CKD stages 1-3 (codes N18.1 to N18.3) are not always considered to have renal failure. When it is documented in the medical record that the patient also has renal failure this must be coded in addition.
• Patients with CKD stages 4 and 5 and CKD with end stage renal failure (codes N18.4 and N18.5) are always considered to have renal failure. Whether renal failure
is documented in the medical record or not it must not be coded in addition; the exception is acute renal failure which must always be coded.

Question 25

DCS.XIV.3: Calculus at the ureteropelvic junction (N20.0)

Answer 25

Calculus at the ureteropelvic junction must be coded using N20.0 Calculus of kidney.

Question 26

DCS.XIV.4: Urinary sphincter weakness incontinence (N39.3)

Answer 26

Urinary sphincter weakness incontinence must be coded using N39.3 Stress incontinence.

Question 27

DCS.XIV.5: Benign prostatic hypertrophy and urethral obstruction (N40.X)

Answer 27

When urethral obstruction is caused by benign prostatic hypertrophy/hyperplasia (BPH), it must not be coded in addition as it is regarded as a symptom of BPH and is therefore implicit in code N40.X Hyperplasia of prostate.

Question 28

DCS.XIV.6: Raised Prostate Specific Antigen [PSA] (R79.8)

Answer 28

In the absence of a definitive diagnosis (such as benign prostatic hypertrophy or malignant neoplasm of prostate) the appropriate code for raised/elevated PSA is R79.8 Other specified abnormal findings of blood chemistry.

Question 29

DCS.XIV.7: Intraepithelial neoplasia and dysplasia of prostate (D07.5, N42.3)

Answer 29

Code D07.5 Carcinoma in situ of prostate must be assigned for a diagnosis of high grade intraepithelial neoplasia of the prostate (HGIN) or high grade dysplasia of the prostate.
Code N42.3 Dysplasia of prostate must be assigned for a diagnosis of Grade I or Grade II prostatic intraepithelial neoplasia or low grade dysplasia of prostate.

Question 30

DCS.XIV.8: Infertility with known cause (N46 and N97)

Answer 30

When a patient has infertility and the cause is known, both conditions must be coded.
Sequencing will depend on the main condition treated or investigated.

Question 31

DCS.XIV.9: Endometriosis (N80)

Answer 31

Multiple codes from category N80.- Endometriosis must be assigned when multiple sites of endometriosis are documented in the medical record.

N80.3 Endometriosis of pelvic peritoneum must be assigned for a diagnosis of endometriosis of the broad ligament.

Question 32

DCS.XIV.11: Female genital mutilation (Z91.7)

Answer 32

When it is documented in the medical record for the current admission that a patient has undergone female genital mutilation (FGM), either as a current injury or as a historical event, code Z91.7 Personal history of female genital mutilation must be assigned in a secondary position, regardless of whether the current admission is for treatment of the FGM or not.

When the patient is being treated or investigated for FGM, and no further information is given about the resultant genital disorder/damage or any other condition resulting from the FGM, the following codes must be assigned:

N90.8 Other specified noninflammatory disorders of vulva and perineum
Z91.7 Personal history of female genital mutilation

When the patient is being treated or investigated for FGM and the specific genital disorder/damage is documented, or the patient is being treated or investigated for another condition that has occurred as a result of FGM, then the following codes must be assigned:

Code for the specific genital disorder/damage, or code for the condition that has
occurred as a result of FGM.
Z91.7 Personal history of female genital mutilation

Question 33

DCS.XIV.12: Prolapse of vaginal vault after hysterectomy (N99.3)

Answer 33

It must be clear in the document that the vaginal prolapse is due to the previous hysterectomy in order to assign N99.3. A code from range Y83-Y84 is not required as it is implicit within the code description.

Question 34

When must the code Z37.- be assigned

Answer 34

A code from category Z37.- must be assigned in the first second diagnostic position on a mother delivery episode only, to identify whether the delivery resulted in a liveborn or stillborn infant(s)

Z37.- must not be assigned on a patient who has undergone a termination or has had a miscarriage and resulted into the delivery of a dead fetus whilst in hospital.

Question 35

What are codes within range O00-O03 and O08 used for?

Answer 35

Codes in categories O00-O03 classify ectopic pregnancy, molar pregnancy and miscarriage before 24 weeks

Codes in category O08.- are used in addition to codes in categories O00-O02 to identify associated complications, and with category O03 to give further information about the complication.

Question 36

How must a missed miscarriage (before 24 weeks) be coded?

Answer 36

O02.1 is used to classify a missed miscarriage, and must only be assigned when there has been no mention of bleeding and no products of conception have been passed. When bleeding is noted or products of conception have been passed, this must be coded to O03.-

Question 37

How must medical management of missed miscarriage (before 24 weeks) be coded?

Answer 37

When a patient with a missed miscarriage has been admitted to receive medication to induce delivery of the retained dead fetus, before 24 weeks without any mention of bleeding, prior to the administration of the medication to induce delivery, code O02.1 must be assigned.

This applies to whether the fetus is passed during the same hospital visit as the induction, or if the patient is given the medication and then discharged home prior to expulsion of the delivery. If the patient is re-admitted with bleeding then a code from O03.- must not be assigned as this is not a spontaneous miscarriage.

Question 38

How must a Spontaneous miscarriage (before 24 weeks) be coded?

Answer 38

If a spontaneous miscarriage occurs before 24 weeks, the episode must be classified using a code from category O03.-

When assigning the fourth character at O03.- the following must be observed:
• Incomplete miscarriage – the miscarriage has started, bleeding is present but not all of the products of conception have passed. Assignment of The fourth character from .0-.4 will depend on whether there were any maternal complications.
• Complete miscarriage – the pregnancy has been lost the uterus is empty and there are no related products of conception. Assignment of The fourth character from .5-.9 will depend on whether there were any maternal complications.

If a patient is readmitted with retained products of conception after a previous spontaneous miscarriage this must be coded as an incomplete spontaneous miscarriage from category O03.- with the relevant fourth character from .0-.4. This also applies is a procedure for the retained products of conception has been carried out on the previous spontaneous miscarriage, as the retained products are considered ongoing treatment of a spontaneous miscarriage.

Question 39

Howw must a termination of pregnancy be coded?

Answer 39

Termination of pregnancy must be coded to O04-O07 irrespective of gestational age (i.e after 24 weeks gestation regardless of whether the baby was liveborn or stillborn)

Retained products of conception after a medical termination is considered to be an incomplete abortion and coded to categories O04-O07 with the corresponding fourth character from .0-.4.

Patients who are admitted for abortifacient drugs or pessaries for the termination of pregnancy must be coded from the range O04 with the appropriate fourth character from range .5-.9 this includes patients who:
• Are kept in hospital and abort the pregnancy whilst in hospital
• Are discharged to abort the pregnancy at home
• Begin to bleed before discharge home to abort the pregnancy

If after the patient has been readmitted with an incomplete termination of pregnancy (retained products of conception) this must be coded to O04- with the appropriate fourth character .0 to .4.

Assign a code from O08 to give further information about the complication of the medical termination.

In cases where a patient undergoes a medical termination of pregnancy resulting in a liveborn (ie alive for any length of time after termination, regardless of gestational age) a code from O04-O06 must be assigned followed by a code from Z37.- in the first secondary position to indicate that the termination resulted in a live born.

O06.- unspecified abortion must not be used for inpatient termination of pregnancy as it would be expected to be documented in the patient’s medical record, if the type of termination is not documented, the coder must obtain this information from the responsible consultant.

The only circumstance where this category can be assigned is for a direct inadvertent loss of pregnancy takes place.

Question 40

How must cancellation of medical termination of pregnancy be coded?

Answer 40

Patients admitted for a medical termination of pregnancy who change their mind resulting
in cancellation of the planned procedure must be coded as follows:

Where the patient has no other conditions present which are classifiable to Chapter XV Pregnancy, childbirth and the puerperium or category Z35.- Supervision of high-risk pregnancy the following codes and sequencing must be used:

Z34.- Supervision of normal pregnancy
Z53.2 Procedure not carried out because of patient’s decision for other and unspecified reasons.

When the reason for the termination of pregnancy is because of a current pregnancy related condition classifiable to Chapter XV Pregnancy, childbirth and the puerperium the following codes and sequencing must be used:

Code from categories O10-O45 or categories O98-O99 that classifies the pregnancy related condition
Z53.2 Procedure not carried out because of patient’s decision for other and unspecified reasons.

When the reason for the termination of pregnancy is because of a history of a pregnancy related condition that is classifiable to categories O10-O92 the following codes and sequencing must be used:

Z35.2 Supervision of pregnancy with other poor reproductive or obstetric history
Z53.2 Procedure not carried out because of patient’s decision for other and unspecified reasons.

When the reason for the termination of pregnancy is because the pregnancy is considered
to be high risk (e.g. the patient is an elderly primigravida, or because of a social problem,
etc) the following codes and sequencing must be used:

Z35.- Supervision of high-risk pregnancy
Z53.2 Procedure not carried out because of patient’s decision for other and unspecified reasons.

Question 41

DCS.XV.17: Reduced fetal movements (O36.8)

Answer 41

The correct code for a patient admitted with reduced fetal movements is O36.8 Maternal care for other specified fetal problems.

Question 42

DCS.XV.18: Premature rupture of membranes (O42)

Answer 42

A code from category O42.- Premature rupture of membranes must only be assigned for premature rupture of membranes before the onset of labour, regardless of the length of gestation.

Question 43

DCS.XV.19: Morbidly adherent placenta (O43.2)

Answer 43

Code O43.2 Morbidly adherent placenta must be assigned following O72.0 Third-stage haemorrhage or O73.0 Retained placenta without haemorrhage when both conditions are documented in the medical record.

Question 44

How must prolonged pregnancy be coded?

Answer 44

Codes in category O48.X Prolonged pregnancy must be used when the pregnancy exceeds 42 weeks or if the responsible consultant documents in the medical record that the patient is ‘post-term’, or ‘post-dates’.

Question 45

DCS.XV.21: Preterm labour and delivery (O60)

Answer 45

A code from this category is used if the labour is spontaneous or induced and if delivery is
vaginal or surgical.

Codes in this category must be used as follows:

O60.0 Preterm labour without delivery

Assign for patients who are admitted in preterm labour and are sent home to await further
events.

For patients with a normal pregnancy admitted in the early stages of term labour (withcontractions) who are subsequently discharged and told to return when the contractions become more established, see DCS.XV.34: Supervision of normal pregnancy (Z34).

O60.1 Preterm spontaneous labour with preterm delivery

Assign for patients who are admitted in preterm labour and go on to deliver a preterm baby
by any means.

O60.2 Preterm spontaneous labour with term delivery

Assign for patients who deliver to term but who at some point during the current pregnancy
have been admitted in spontaneous preterm labour. The labour may have stopped by itself or delayed with the help of medication such as tocolytics. In some instances, the patient may go on to deliver to term naturally, during the same hospital provider spell.
If the patient has gone home in between the preterm labour stopping and the term delivery, this code must only be assigned on the delivery episode if it is documented in the medical record that they were previously admitted in preterm labour.

O60.3 Preterm delivery without spontaneous labour

Assign when the patient or the fetus has a condition which requires either an induced preterm delivery or caesarean section preterm delivery. This code must be used in addition to the code describing the condition prompting the preterm delivery.

Question 46

DCS.XV.24: Failed trial of labour, unspecified (O66.4) and Failed application of vacuum extractor and forceps, unspecified (O66.5)

Answer 46

Codes O66.4 Failed trial of labour, unspecified and O66.5 Failed application of vacuum extractor and forceps, unspecified must not be used if the condition giving rise to the intervention is known.

Question 47

DCS.XV.25: Postpartum haemorrhage (O72)

Answer 47

Codes in category O72.- Postpartum haemorrhage must only be coded when documented as such in the patient’s medical record by the responsible consultant.
The levels of blood loss must not be interpreted by the coder in order to decide if the levels constitute a diagnosis of postpartum haemorrhage.

The responsible consultant must always be consulted to confirm the clinical significance of a high level of blood loss if a diagnosis of postpartum haemorrhage has not been specifically documented in the medical
record.

Question 48

DCS.XV.26: Delayed delivery (O75.5, O75.6)

Answer 48

It must be stated in the medical record that the delivery was delayed for either code O75.5
Delayed delivery after artificial rupture of membranes or O75.6 Delayed delivery after spontaneous or unspecified rupture of membranes to be assigned.

Question 49

DCS.XV.27: Vaginal delivery following previous caesarean section (O75.7)

Answer 49

If it is documented in the patient’s medical record that the mother has delivered vaginally following a previous caesarean section (regardless of how far in the past that caesarean section was), code O75.7 Vaginal delivery following previous caesarean section must be assigned, in either a primary or secondary position.

Question 50

DCS.XV.28: Delivery (O80–O84)

Answer 50

Codes in categories O80–O84 Delivery must only be used when the only information recorded is a statement of ‘delivery’ or when only the method of delivery has been recorded and the patient has no other conditions classifiable to Chapter XV.

In the case of multiple births, a code from O84.- Multiple delivery must not be used. A code from category O30.- Multiple gestation must be assigned instead.

Question 51

DCS.XV.29: Obstetric death (O95-O97)

Answer 51

Codes in categories O95–O97 must not be used for morbidity coding.

Question 52

DCS.XV.30: Human immunodeficiency virus [HIV] disease complicating pregnancy,
childbirth and the puerperium (O98.7)

Answer 52

Code O98.7 Human immunodeficiency virus [HIV] disease complicating pregnancy, childbirth and the puerperium must be assigned whenever a patient with HIV is admitted during pregnancy, childbirth and the puerperium as HIV always complicates pregnancy.

For patients with symptomatic (active) HIV – assign an additional code from categories B20-B24 Human immunodeficiency virus [HIV] disease in a secondary position.

For patients with asymptomatic (non-active or HIV positive) HIV – assign the code Z21.X Asymptomatic human immunodeficiency virus [HIV] infection status in a secondary position.

Question 53

DCS.XV.31: Other maternal diseases classifiable elsewhere but complicating pregnancy, childbirth and the puerperium (O99)

Answer 53

Conditions that complicate the pregnant state, are aggravated by the pregnancy, or are a main reason for obstetric care (this includes pre-existing conditions) which are not classified elsewhere within Chapter XV must be coded using a code from category O99.-
Other maternal diseases classifiable elsewhere but complicating pregnancy, childbirth and the puerperium. An additional code must be used to identify the specific condition where it adds information.

Where a pregnant patient has a condition which is present but is not complicating the pregnant state, aggravating the pregnancy, or the main reason for obstetric care a code from O99.- must not be used, only a code for the condition is assigned.

Conditions that are pregnancy induced and are not classified elsewhere within Chapter XV must be coded using a code from category O26.- Maternal care for other conditions predominantly related to pregnancy,

Question 54

DCS.XV.32: Anaemia complicating pregnancy, childbirth and the puerperium (O99.0)

Answer 54

O99.0 Anaemia complicating pregnancy, childbirth and the puerperium must only be assigned when it is documented in the medical record that the patient has anaemia complicating pregnancy, childbirth or the puerperium. Statements such as ‘low Hb’ or ‘sent
home on iron tablets’ must not be used as an indication that this code should be used.

An additional code from the range D50–D64.8 must be used if the type of anaemia is known.

Question 55

DCS.XV.33: Pregnant state, incidental (Z33.X)

Answer 55

Code Z33.X Pregnant state, incidental must never be used in a primary position. Z33.X is only assigned in a secondary position when a pregnant patient is treated for an unrelated condition that does not affect or complicate the management of the pregnancy.

Question 56

DCS.XV.34: Supervision of normal pregnancy (Z34)

Answer 56

A code from category Z34.- Supervision of normal pregnancy must be assigned for patients who are:
• admitted for a suspected problem related to the pregnancy where on further examination no abnormality relating to the pregnancy is found

and

• they have not received treatment or investigation for any other condition that is classifiable to Chapter XV.

Codes in this category must also be used for patients with a normal pregnancy admitted in the early stages of term labour (with contractions) who are subsequently discharged and told to return when the contractions become more established. If the responsible consultant confirms that the patient is in preterm labour and they are sent home to await further events code O60.0 Preterm labour without delivery must be used instead.

Codes in category Z34.- Supervision of normal pregnancy must not be assigned when the responsible consultant has made a diagnosis of Braxton-Hicks contractions or false labour, which are classified to category O47.- False labour.

Question 57

DCS.XV.35: Care and examination immediately after delivery (Z39.0)

Answer 57

Z39.0 Care and examination immediately after delivery must be assigned for patients who have given birth outside of hospital and are admitted for a postpartum check and no complications are found. If any complications are found on examination a different code from Chapter XV must be assigned instead.

Question 58

DCS.XV.6: Haemorrhage in early pregnancy (O20)

Answer 58

Codes in category O20.- Haemorrhage in early pregnancy must be used for any vaginal
bleeding before 24 completed weeks of gestation, except when the pregnancy proceeds to
abortive outcome when a code from categories O00-O08 Pregnancy with abortive outcome must be used instead.

If a threatened miscarriage (O20.0 Threatened abortion) proceeds to miscarriage then this must be coded to O03.- Spontaneous abortion

Question 59

DCS.XV.9: Diabetes mellitus in pregnancy (O24)

Answer 59

Diabetes mellitus in pregnancy, childbirth and the puerperium must always be coded using
a code from category O24.- Diabetes mellitus in pregnancy.

If the diabetes is causing manifestations these must be coded in addition. Where appropriate a dagger and asterisk combination will be used.

Question 60

DCS.XV.10: Maternal care for other conditions predominantly related to pregnancy
(O26)

Answer 60

Condition that are pregnancy induced and are not classifiable to anywhere else in chapter XV must be coded to a code in category O26.-, an additional code specifying the condition must be used in addition this includes symptoms, signs and abnormal results from chapter XVIII.

The exception to this Is when coding obstetric cholestasis using O26.6, Cholestasis is an explicit inclusion at code O26.6 a further code is not required.

Conditions that complicated the state, are aggravated by the pregnancy state, or are the main reason for obstetric care not classified elsewhere in chapter XV are classified to O99.-

Question 61

DCS.XV.11: Abnormal findings on antenatal screening of mother (O28)

Answer 61

Codes in this category must only be used when an abnormal finding does not result in a definitive diagnosis.

Question 62

DCS.XV.13: Complications of anaesthesia during pregnancy, labour, delivery and the puerperium (O29, O74, O89)

Answer 62

When coding complications of anaesthesia at O29, )74 or O89

code assignment must reflect the stage of pregnancy when the anaesthesia was administered
(i.e. pregnancy, labour and/or delivery, or during the puerperium), and not the stage when the complication(s) arose.

Question 63

DCS.XV.14: Multiple gestation (O30)

Answer 63

When recording an episode with a normal multiple delivery, a code from category O30.-
Multiple gestation must be recorded as the primary diagnosis, unless the patient has a
condition classified to another code from Chapter XV on the delivery episode, in which
case the appropriate code from category O30.- must be recorded in a secondary position.

Question 64

DCS.XV.15: Maternal care for known or suspected malpresentation of fetus,
disproportion and abnormality of pelvic organs (O32–O34) and Obstructed labour
(O64-O66)

Answer 64

Codes in categories O32-O34 are assigned when the listed condition is a reason for observation, hospitalisation or other obstetric care of the mother or for caesarean section, at any point during pregnancy, labour or delivery.

If a condition in categories O32-O34 is diagnosed during labour the code from these categories must still be assigned, unless the responsible consultant confirms that the labour is obstructed or if the ICD-10 index trail directs the coder to an obstructed labour
code, in which case a code from categories O64–O66 must be used instead.

Question 65

DCS.XV.16: Maternal care for intrauterine death (O36.4)

Answer 65

The code O36.4 must be assigned for stillbirths and late intrauterine deaths, where it is known before delivery that the fetus has no signs of life.

If the cause of death is known, code O36.4 must be assigned in a secondary position to the code(S) which describes the cause of death.

A code from Z37.- must be used in the first secondary position on all stillbirth and late intrauterine death episodes delivery episodes.

If it is not known before delivery that there is a stillborn or late intrauterine death the code O36.4 must not be used. A different code from chapter XV must be assigned. A code from Z37.- would still be required to indicate that the outcome was a stillbirth