Here are 3 tips for keeping abreast of gynecology coding tips in the first year of ICD-10.
1. Know definition changes. Under ICD-10, the documentation of trimesters is required, according to CMS. Trimesters are documented in weeks. The definitions are as follows:
• First trimester: Less than 14 weeks, 0 days
• Second trimester: 14 weeks, 0 days through 27 weeks and six days
• Third trimester: 28 weeks through delivery
ICD-10 includes a number of definition changes related to abortion. The timeframe for a missed abortion, as opposed to fetal death, has changed from 22 weeks to 20 weeks.
Definitions of spontaneous abortion under ICD-10 include:
• Missed abortion: No bleeding, os closed
• Threatened abortion: Bleeding, os closed
• Incomplete abortion: Bleeding, os open, products of conception are extruding
• Complete abortion: Possible bleeding or spotting, os closed, all products of conception expelled
An elective abortion is termed an "elective termination of pregnancy."
2. Understand specificity requirements. Increased specificity is needed in several areas of gynecology including intent of encounter, pregnancy complications and alcohol use, substance abuse and tobacco dependence.
When documenting the intent of an encounter, be sure to specify the type of encounter and any complications discovered during the encounter.
ICD-10 demands increased specificity in pregnancy complications in the following areas:
• Condition detail
• Trimester
• Casual relationship
In regard to alcohol use, substance abuse and tobacco dependency, documentation needs to specifically indicate the mother's use or non-use of alcohol, substances or tobacco and the risk to the child.
Another area of specificity to be aware of is the effects of advanced maternal age and risk of complicated pregnancy, according to ObGyn.net. Specificity requirements indicate physicians should document if a patient is 35 years or older and if this is a factor in child delivery.
3. Be familiar with documentation requirements. Along with increased specificity in documentation, there are a number of key documentation requirements to know, according to ObGyn.net. Documentation issues to be aware of include:
• Reasons for fetus viability scans. Document whether the scan was routine or done for a particular reason.
• Pelvic pain cause. Document the cause of pelvic pain with as much detail as possible.
• Migraines. Document if a patient is specifically having menstrual migraines. Indicate if the migraines are intractable or not.
Click here to view all CMS' "Road to 10" tools for gynecology.