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ICD-10 Coding for OB/GYN Flashcards

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  1. A patient delivers a single liveborn infant at 39 weeks via uncomplicated spontaneous vaginal delivery. Which code set is correct?

    Answer: O80, Z3A.39, Z37.0

    O80 = full-term uncomplicated delivery; Z3A.39 = 39 weeks gestation; Z37.0 = outcome of delivery, single liveborn infant.

  2. The outcome of delivery code from category Z37 is:

    Answer: Always assigned as a secondary code on the maternal delivery record

    Z37 outcome-of-delivery codes are required secondary codes on the maternal record for every delivery encounter.

  3. A patient undergoes a cesarean section due to a breech-presenting fetus at 39 weeks with no other documented complications. What is the principal ICD-10-CM diagnosis?

    Answer: O32.1XX0 – Maternal care for breech presentation, single fetus

    The indication for the cesarean (breech presentation, O32.1XX0) is sequenced as principal diagnosis; O82 is reserved for cesarean deliveries with no documented clinical indication.

  4. A patient at 35 weeks has premature rupture of membranes (PROM) with labor beginning within 24 hours. Which ICD-10-CM code applies?

    Answer: O42.013 – Preterm PROM, onset of labor within 24 hours, third trimester

    35 weeks is in the third trimester (28+ weeks); labor began within 24 hours of rupture; therefore O42.013 (preterm PROM, onset within 24 hours, third trimester) is correct.

  5. A patient at 34 weeks has complete placenta previa with active hemorrhage. Which ICD-10-CM code is correct?

    Answer: O44.13 – Complete placenta previa with hemorrhage, third trimester

    34 weeks is in the third trimester; the hemorrhage subcategory of complete placenta previa is O44.1; combined with trimester designation, the code is O44.13.

  6. Puerperal sepsis following delivery is coded as:

    Answer: O85 – Puerperal sepsis

    O85 is the specific ICD-10-CM code for puerperal sepsis; ICD-10-CM guidelines instruct coders to use O85 rather than sequencing a general sepsis code from Chapter 1.

  7. A second-degree perineal laceration occurring during vaginal delivery is coded as:

    Answer: O70.1 – Second degree perineal laceration during delivery

    O70.1 represents a second-degree perineal laceration that involves the perineal body muscles but does not extend to the anal sphincter.