In the coming year, everybody is anticipating the coding and billing changes and ob-gyn practice is no exception. Amongst all the changes, here are a few to help you ease the transition process to ICD-10 for ob-gyn and help you in your ob-gyn coding training.For anything related to contraception, your physician needs to document the type of contraception that was discussed. On the other hand, patients may come up for discussion on contraceptive measures and not have any specific complaints. So after October 1, 2014, you need to choose from the following codes:
Z30.011 with the description Encounter for initial prescription of contraceptive pills
Z30.012 with the description Encounter for prescription of emergency contraception
Z30.013 with the description Encounter for initial prescription of injectable contraceptive
Z30.014 with the description Encounter for initial prescription of intrauterine contraceptive device
Z30.018 with the description Encounter for initial prescription of other contraceptives
Z30.019 with the description Encounter for general counseling and advice on contraception, unspecified
Z30.02 with the description Counseling and instruction in natural family planning to avoid pregnancy
Z30.09 with the description Encounter for general counseling and advice on contraception
If "encounter for family planning advice NOS" has been documented by your provider then Z30.09 should be reported.Next, if a patient who is pregnant reports to your practice, but the complaint has been documented as "incidental" for the pregnancy, then in this case one should report this along with another code that is outside of the obstetric complications chapter of ICD-10 that signifies the complaint.
Under ICD-9, it was being reported with V22.2 with the description Pregnancy state, incidental, but when ICD-10 sets in the code Z33.1 with the description Pregnancy state, incidental needs to be used. Although the code description is the same, the codes are different.While documenting, it is essential for the provider to document that the pregnancy is incidental and mention it in the chart note when the encounter is done to ensure you can use this code.Additionally, while reporting polyuria 788.42 changes to a new code. Any patient suffering from polyuria indicates that there is excessive or more than usual production of urine. Under ICD-9, the code used to report this is 788.42 with the description Polyuria. But as soon as ICD-10 sets in, you need to use R35.8 with the description Other polyuria and there is a direct co-relation between 788.42 and R35.8. When it comes to documentation, your provider can document it as "Polyuria NOS."Tip: You should not confuse polyuria with urinary frequency. Urinary frequency needs to be reported using the code R35.0 with the description Frequency of micturition. Also ensure that you steer clear of any confusion with nocturia which indicates that the patient has a tendency to wake up in the middle of the night to urinate. This condition needs to be reported with the code R35.1 with the description nocturia.