Example 1:

Clinical history: Morbid obesity
Gross exam: Received fresh specimen labeled 38.5 week placenta. It consists of 18x15x4 cm placenta with attached umbilical cord and fetal membranes. The umbilical cord is 27 cm in length and inserts 3.5 cm from the nearest membrane margin. The cord shows normal coiling. No knots identified. 3 vessels are present. The placenta weighs 632g. No lesions identified. All surfaces are normal.
Sections submitted: 1A, cord and membranes; 1B-1E, placenta.
Final Diagnosis: Placenta delivery: Normal findings.

Example 2:

Clinical history: IUP at 36.3 weeks gestation, IUGR
Gross exam: Received fresh specimen labeled third trimester placenta. It consists of 15x12x3.2 cm placenta with attached umbilical cord twists/coils and fetal membranes. The umbilical cord is 45 cm in length and inserts 2.3 cm from the nearest membrane margin. The cord is hyper-coiled. 2 vessels are present. The placenta weighs 407g. Membranes show inflammatory cells. All surfaces appear normal.
Sections submitted: 1A, cord and membranes; 1B-1E, placenta.
Final Diagnosis: Placenta delivery: Placental insufficiency.

ATC PATH ReveNews Oct

These two examples may look similar in some ways but the true difference and the key is documentation. In a majority of cases, ICD-10-CM requires that the trimester is documented in order to code the highest level of specificity. In the first example, you will see a new term present in ICD-10 “in childbirth”. Per ICD-10 Chapter 5 a. 3., "[w]henever delivery occurs during the current admission, and there is an "in childbirth" option for the obstetric complication being coded, the "in childbirth" code should be assigned."

In the second example, the trimester is documented and this series of codes require a 7th character to describe the fetus identification (i.e., single, fetus 1, 2 etc). Per ICD-10 Chapter a 5, “[t]he unspecified trimester code should rarely be used.”

Reference

  • 2014 ICD-9-CM Professional Manual (AMA) page 238 (vol 2/alpha), 202 & 62, 204 (vol1/tabular)
  • 2015 Draft ICD 10-CM Manual (AMA) page 15 (ICD-10 Guidelines), 253, 204 (vol 2/alpha), 761 & 489, 750 (vol 1 tabular)
Author - Female

About the author

Kimberly West, CPC is National Pathology Auditing & Coding Manager of McKesson Business Performance Services.