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Anatomy and Pathophysiology

for ICD-10

Module 13

ii Anatomy and Pathophysiology for ICD-10 © 2013 AAPC. All rights reserved. 111213

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Content

Module 13 Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Diseases and Disorders in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

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Module13

Pregnancy

TerminologyAmenorrhea—Absence of menses.

Amniotoic fluid—Liquid produced by (and contained within) the fetal membranes during pregnancy.

Cesarean section—Surgical procedure where the baby is delivered transabdominally.

Eclampsia—Most severe form of hypertension during pregnancy.

EDD—Expected date of delivery.

Embryo—Name given to product of conception from the second through eighth week of pregnancy.

Endometrium—Inner lining of the uterus.

LMP—Last menstrual period.

Ovum—Female sex cell.

Umbilical cord—Serves as a lifeline to the fetus.

Zygote—Fertilized ovum.

IntroductionPregnancy starts with fertilization and ends with child-birth in an average span of 38 weeks. During the gesta-tional period the zygote divides as it passes through the fallopian tube and attaches to the uterine lining via implantation. Through complex sequences of develop-ment the zygote is transformed into a full-term fetus.

Amnioticspace

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Course of PregnancyA scientific term for pregnancy is gravid, thus referring to a pregnant female as gravida. The term parity (used as para) is used for the number of previous successful live births. So, a woman currently pregnant with her third baby with two live births previously is considered Gravida 3 Para 2. Other pregnancy terms:

• Nulligravida—A woman who has never been pregnant (also called nulliparous)

• Primigravida—A woman pregnant for the first time • Multigravida—A woman in a subsequent pregnancy

(also called multiparous)• Abortion—Death of embryo or fetus whether

spontaneous or induced

2 Anatomy and Pathophysiology for ICD-10 © 2013 AAPC. All rights reserved. 111213

Pregnancy Module 13

The course of pregnancy is usually broken down into trimesters. According to ICD-10-CM the break down for the trimesters are:

• 1st trimester—less than 14 weeks 0 days• 2nd trimester—14 weeks 0 days to less than 28

weeks 0 days• 3rd trimester—28 weeks 0 days until delivery

First TrimesterTraditionally, doctors have measured pregnancy from a number of convenient points, including the day of last menstruation, ovulation, fertilization, implanta-tion, and chemical detection. In medicine, pregnancy is often defined as beginning when the developing embryo becomes implanted into the endometrial lining of a woman’s uterus. Most pregnant women do not have any specific signs or symptoms of implantation, although it is not uncommon to experience minimal bleeding at implantation. Some women will also experience cramping during their first trimester. This is usually of no concern unless there is spotting or bleeding as well. After implantation the uterine endometrium is called the decidua. The placenta, which is formed partly from the decidua and partly from outer layers of the embryo, connects the developing fetus to the uterine wall to allow nutrient uptake, waste elimination, and gas exchange via the mother’s blood supply. The umbilical cord is the connecting cord from the embryo or fetus to the placenta. The developing embryo undergoes tremen-dous growth and changes during the process of fetal development.

In some cases a complication may occur where the fertil-ized egg might implant itself in the fallopian tubes, the cervix, and the ovary—or in the abdomen, causing an ectopic pregnancy. In the case of an ectopic pregnancy there is no way for the pregnancy to progress normally. If left untreated, it can cause harm and possibly death for the mother when a rupture occurs. It may go away on its own, or it may need surgical removal or medicine to remove the tubal pregnancy since there is no way of the pregnancy being able to continue safely.

A common occurrence in pregnancy is morning sick-ness. About 70 percent of all pregnant women will encounter this condition and it typically improves after the first trimester. Although described as “morning

sickness,” women can experience this nausea during afternoon, evening, and throughout the entire day.

In the first 12 weeks of pregnancy, the nipples and areolas darken due to a temporary increase in hormones. The first two weeks from the first trimester are calcu-lated as the first two weeks of pregnancy even though the pregnancy does not actually exist. These two weeks are the two weeks before conception and include the woman’s last period.

The third week is the week in which fertilization occurs and the fourth week is the period when implantation takes place. In the fourth week, the fecundated egg reaches the uterus and burrows into its wall which provides it with the nutrients it needs. At this point, the zygote becomes a blastocyst and the placenta starts to form. Moreover, most of the pregnancy tests may detect a pregnancy beginning with this week.

The fifth week marks the start of the embryonic period. This is when the baby’s brain, spinal cord, heart and other organs begin to form. At this point the embryo is made up of three layers, of which the top one (called the ectoderm) will give rise to the baby’s outermost layer of skin, central and peripheral nervous systems, eyes, inner ear, and many connective tissues. The heart and the beginning of the circulatory system as well as the bones, muscles and kidneys are made up from the mesoderm (the middle layer). The inner layer of the embryo will serve as the starting point for the development of the baby’s lungs, intestine and bladder. This layer is referred to as the endoderm. A baby at five weeks is normally between 1⁄16 and 1⁄8 inch (1.6 and 3.2 mm) in length.

In the 6th week, the baby will be developing basic facial features and its arms and legs start to grow. At this point, the embryo is usually no longer than 1⁄6 to 1⁄4 inch (4.2 to 6.3 mm). In the following week, the brain, face, arms, and legs quickly develop. In the 8th week, the baby starts moving and in the next three weeks, the baby’s toes, neck, and genitals develop as well. By the end of the first trimester, the fetus will be about 3 inches (76 mm) long and will weigh approximately 1 ounce (28 g).

Second TrimesterMost women feel more energized in the second trimester and begin to put on weight as the symptoms of morning sickness subside and eventually fade away. In the 20th


Module 13 Pregnancy

week the uterus can expand up to 20 times its normal size during pregnancy. In the second trimester quick-ening occurs, when movement of the fetus is finally felt. This typically happens in the fourth month, more specifically in the 20th to 21st week, or by the 19th week if the woman has been pregnant before. However, it is not uncommon for some women not to feel the fetus move until much later. The placenta fully functions at this time and the fetus makes insulin and urinates. The reproduc-tive organs distinguish the fetus as male or female.

Third TrimesterFinal weight gain takes place, which is the most weight gain throughout the pregnancy. The fetus will be growing the most rapidly during this stage, gaining up to 28 g per day. The woman’s belly will transform in shape and her belly will drop because the fetus is turning in a down-ward position to get ready for birth. The fetus begins to move regularly, and can be felt often by the woman. Fetal movement can become quite strong at this point. Sometimes the woman’s navel will pop out and become convex. This period of her pregnancy can be uncomfort-able due to: symptoms such as weak bladder control and backache, feeling the fetus “rolling” causing pain and discomfort if the is near the woman’s ribs or spine.

The fetus’ movement becomes stronger and more frequent due to improved eye, brain, and muscle function. Head engagement occurs when the fetal head descends into the pelvic cavity. This is termed as the baby dropping or the lightening. However, it severely reduces bladder capacity and increases pressure on the pelvic floor and the rectum. This sometimes causes the mother to experience the perpetual sensation that the fetus will “fall out” at any moment. The perineum and cervix are further flattened and the head may be felt vaginally.

Complications of PregnancyPregnancy poses varying levels of health risks for women, depending on their medical profile before pregnancy.

The following are some of the complaints that may occur during and/or after pregnancy due to the many changes which pregnancy causes in a woman’s body:

• Anemia • Back pain. A common complaint in the third trimes-

ter when the patient’s center of gravity has shifted.

• Constipation. A complaint that is caused by decreased bowel mobility secondary to elevated progesterone which can lead to greater absorption of water.

• Braxton Hicks contractions. Occasional, irregular, and often painless contractions that occur several times per day.

• Edema. Common complaint in advancing pregnancy. Caused by compression of the inferior vena cava (IVC) and pelvic veins by the uterus leads to increased hydrostatic pressure in lower extremities.

• Regurgitation, heartburn, and nausea. May be caused by Gastroesophageal Reflux Disease (GERD).

• Hemorrhoids. Complaint that is often noted in advancing pregnancy. Caused by increased venous stasis and IVC compression leading to congestion in venous system, along with increased abdominal pressure secondary to the pregnant space-occupying uterus and constipation.

• Pelvic girdle pain (PGP). This disorder is complex and multi-factorial and likely to be represented by a series of sub-groups with different underlying pain drivers. Musculo-Skeletal Mechanics involved in gait and weight-bearing activities can be mild to grossly impaired. PGP can begin peri or postpartum. There is pain, instability, or dysfunction in the symphysis pubis and/or sacroiliac joints.

• Round Ligament Pain. Pain experienced when the ligaments positioned under the uterus stretch and expand to support the woman’s growing uterus.

• Thromboembolic disorders. A leading cause of death in pregnant women.

• Increased urinary frequency. Caused by increased intravascular volume, elevated GFR (glomerular filtration rate), and compression of the bladder by the expanding uterus.

• Urinary tract infection • Varicose veins. Caused by relaxation of the venous

smooth muscle and increased intravascular pressure.• Pruritic Urticarial Papules and Plaques of Pregnancy

(PUPPP). This is a skin disease that develops around the 32nd week with itchiness around the belly button and red plaques and papules that spread all over the body except for the inside of the hands and face.


Pregnancy Module 13

• Postpartum depression• Postpartum psychosis

ChildbirthChildbirth, or labor, birth, partus, parturition. This is the end of the pregnancy with the birth of one or more newborn infants. A woman is considered to be in labor when she begins experiencing regular uterine contrac-tions, accompanied by changes of her cervix—primarily effacement and dilation. All changes in the soft tissues of the cervix and the birth canal depend on the successful completion of these six phases:

1. Engagement of the fetal head in the transverse position. The baby’s head is facing across the pelvis at one or other of the mother’s hips.

2. Descent and flexion of the fetal head.

3. Internal rotation. The fetal head rotates 90 degrees to the occipito-anterior position so that the baby’s face is towards the mother’s rectum.

4. Delivery by extension. The fetal head passes out of the birth canal. Its head is tilted backwards so that its forehead leads the way through the vagina.

5. Restitution. The fetal head turns through 45 degrees to restore its normal relationship with the shoulders, which are still at an angle.

6. External rotation. The shoulders repeat the cork-screw movements of the head, which can be seen in the final movements of the fetal head.

Latent PhaseThe latent phase of labor (prodromal labor) may last many days and the contractions are an intensification of the Braxton-Hicks contractions that may start around 26 weeks gestation. Cervical effacement occurs during the closing weeks of pregnancy and is usually complete or near complete, by the end of the latent phase. The degree of cervical effacement may be felt during a vaginal examination. A ‘long’ cervix implies that not much has changed in the lower segment, and vice versa for a ‘short’ cervix. Latent phase ends with the onset of active first stage; when the cervix is about 3 cm dilated.

First Stage: DilationThere are several factors that midwives and clinicians use to assess the laboring mother’s progress, and these are defined by the Bishop Score. The total score is achieved by assessing the following five components on vaginal examination:

• Cervical dilation• Cervical effacement• Cervical consistency• Cervical position• Fetal station

The Bishop score grades patients who would be most likely to achieve a successful induction. Each compo-nent is given a score of 0-2 or 0-3. The highest possible score is 13. The duration of labor is inversely correlated with the Bishop score; a score that exceeds 8 describes the patient most likely to achieve a successful vaginal birth. Bishop scores of less than 6 usually require that a cervical ripening method be used before other methods.

The first stage of labor starts classically when the effaced cervix is 3 cm dilated. There is a variation in this point as some women may or may not have active contractions prior to this. The onset of actual labor is defined when the cervix begins to progressively dilate, with or without rupture of the membranes or a blood stained ‘show’.

Uterine muscles form opposing spirals from the top of the upper segment of the uterus to its junction with the lower segment. During effacement, the cervix becomes incorporated into the lower segment of the uterus. During a contraction, these muscles contract causing shortening of the upper segment and drawing upwards of the lower segment, in a gradual expulsive motion. This draws the cervix up over the baby’s head. Full dila-tion is reached when the cervix has widened enough to allow passage of the baby’s head, around 10 cm dilation for a term baby.

The duration of labor varies widely. Active phase arrest is defined in a primigravida woman as the failure of the cervix to dilate at a rate of 1.2 cm/hr over a period of at least two hours. This definition is based on Friedman’s Curve, which plots an ideal rate of cervical dilation and fetal descent during active labor.


Module 13 Pregnancy

Breech

Mother'spelvis

ObliqueFace

(mentum)

Compound(extremitytogether

with head)

Shoulder(arm

prolapse)

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Second Stage: Fetal ExpulsionThis stage begins when the cervix is fully dilated, and ends when the baby is finally born. As pressure on the cervix increases, the Ferguson reflex increases uterine contractions so that the second stage can go ahead. At the beginning of the normal second stage, the head is fully engaged in the pelvis; the widest diameter of the head has successfully passed through the pelvic brim. Ideally it has successfully also passed below the inter-spinous diameter which is the narrowest part of the pelvis. If these have been accomplished, what remains is for the fetal head to pass below the pubic arch and out through the introitus. This is when the mother assists by “bearing down” or pushing. The fetal head is seen to ‘crown’ as the labia part. At this point, the woman may feel a burning or stinging sensation.

Birth of the fetal head signals the successful completion of the fourth mechanism of labor (delivery by extension), and is followed by the fifth and sixth mechanisms (resti-tution and external rotation). The second stage of labor will vary to some extent, depending on how successfully the preceding tasks have been accomplished.

Third Stage: Umbilical Cord Closure and Placental ExpulsionThe third stage of labor is the period from just after the fetus is expelled until just after the placenta is expelled. The umbilical cord is routinely clamped and cut in this stage, but it would normally close naturally even if not

clamped. Placental expulsion begins as a physiological separation from the wall of the uterus. The placenta is usually expelled within 15–30 minutes of the baby being born. Placental expulsion can be managed actively, for example by giving oxytocin via intramuscular injec-tion followed by cord traction to assist in delivering the placenta. Alternatively, it can be managed expectantly, allowing the placenta to be expelled without medical assistance.

The ICD-10-CM codes for pregnancy can be found in chapter 15, Pregnancy, Childbirth and the Puerperium, O00–O9a. To code this in ICD-10-CM the following is necessary:

• Trimester• Gestational condition or pre-existing• Type of complication

Following are examples of ICD-10-CM pregnancy codes:

Supervision of pregnancy with history of ectopic or molar pregnancy, unspecified trimester

O09.10

Supervision of pregnancy with history of ectopic or molar pregnancy, first trimester O09.11

Supervision of pregnancy with history of ectopic or molar pregnancy, second trimester

O09.12

Supervision of pregnancy with history of ectopic or molar pregnancy, third trimester O09.13

As demonstrated in the codes above, sometimes the trimester is built into the code. According to the guide-lines, assignment of final character for trimester should be based on the trimester for the current admission/encounter. This applies to the assignment of trimester for pre-existing conditions as well as those that develop during or are due to the pregnancy. Whenever 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.


Pregnancy Module 13

Maternal care for (suspected) central nervous system malformation in fetus O35.0

Maternal care for (suspected) chromosomal abnormality in fetus O35.1

Maternal care for (suspected) hereditary disease in fetus O35.2

Maternal care for (suspected) damage to fetus from viral disease in mother O35.3

Maternal care for (suspected) damage to fetus from alcohol O35.4

In the codes above, the 7th character extender is necessary. It is shown in the next table.

One of the following 7th characters is to be assigned to each code under category O35. 7th character 0 is used for single gestations and multiple gestations where the fetus is unspecified. 7th characters 1 through 9 are for cases of multiple gestations to identify the fetus for which the code applies. The appropriate code from category O30, Multiple gestations, must also be assigned when assigning a code from category O35 that has a 7th character of 1 through 9.

0 not applicable or unspecified

1 fetus 1

2 fetus 2

3 fetus 3

4 fetus 4

5 fetus 5

9 other fetus

Since the 7th character extender is required on the codes, the dummy placeholders must be used along with the codes. For example, if a woman with a single gestation

is seen for a suspected chromosomal abnormality in the fetus, it would be coded to O35.1xx1.

Single live birth Z37.0

Single stillbirth Z37.1

Twins, both liveborn Z37.2

Twins, one liveborn and one stillborn Z37.3

Twins, both stillborn Z37.4

According to the guidelines, a code from category Z37, Outcome of delivery, should be included on every maternal record when a delivery has occurred. These codes are not to be used on subsequent records or on the newborn record.

Where applicable, a 7th character is to be assigned for certain categories to identify the fetus for which the complication code applies.

Assign 7th character “0”:

• For single gestations• When the documentation in the record is

insufficient to determine the fetus affected and it is not possible to obtain clarification

• When it is not possible to clinically determine which fetus is affected

Other important guidelines for chapter 15 state that codes from this chapter have sequencing priority over codes from other chapters. Additional codes from other chapters may be used in conjunction with chapter 15 codes to further specify conditions. Should the provider document that the pregnancy is incidental to the encounter, then code Z33.1 Pregnant state, incidental, should be used in place of any chapter 15 codes. It is the provider’s responsibility to state that the condition being treated is not affecting the pregnancy.

In instances where a patient is admitted to a hospital for complications of pregnancy during one trimester and remains in the hospital into a subsequent trimester, the trimester character for the antepartum complication code should be assigned to the trimester in which the complications developed.


Module 13 Pregnancy

For routine prenatal visits in the outpatient setting when there are no complications, a code from category Z34, Encounter for supervision of normal pregnancy, should be used as the first-listed diagnosis. These codes should not be used in conjunction with chapter 15 codes.

In many cases in this chapter, multiple codes are also necessary to code a complete diagnosis. For example, a woman in her second trimester with a group A strep kidney infection would be coded with O23.01 Infec-tions of kidney in pregnancy, second trimester and B95.0 Streptococcus, group A, as the cause of disease classified elsewhere.

Diseases and Disorders in PregnancyEctopic PregnancyAn ectopic pregnancy occurs when there is an abnormal implantation of a fertilized ovum outside of the uterine cavity, most often referred to as a tubal pregnancy. Approximately 90% of all ectopic pregnancies occur in the fallopian tubes. To code ectopic pregnancies in ICD-10-CM you need to know:

• location of pregnancy

Abdominal pregnancy O00.0

Tubal pregnancy O00.1

Ovarian pregnancy O00.2

Other ectopic pregnancy O00.8

Ectopic pregnancy unspecified O00.9

AbortionAn abortion is the term used to describe a termination of pregnancy before the fetus has reached a viable age. The term abortion is a medical term used to denote any type of termination of pregnancy. Many use the term miscar-riage to describe a spontaneous abortion. A spontaneous abortion is one that occurs on it’s own due to abnor-malities of the embryo or fetus. Symptoms can include vaginal bleeding, rhythmic uterine cramping, continual backache, and a feeling of pressure in the pelvic area.

To code abortions in ICD-10-CM you need to know:

• type• complications• complete vs incomplete• stage of gestation

Missed abortion O02.1

Delayed or excessive hemorrhage following incomplete spontaneous abortion

O03.1

Unspecified complication following incomplete spontaneous abortion

O03.30

Incomplete spontaneous abortion without complication

O03.4

Delayed or excessive hemorrhage following complete or unspecified abortion

O03.6

Unspecified complication following complete or unspecified spontaneous abortion

O03.80

Delayed or excessive hemorrhage following induced termination of pregnancy

O04.6

Genital tract and pelvic infection following failed attempted termination of pregnancy

O07.0

Gestational DiabetesThis disorder develops during the latter part of preg-nancy and the symptoms usually disappear at the end of pregnancy. Women who have gestational diabetes have a higher possibility of developing it with subse-quent pregnancies. Gestational diabetes is an inability to metabolize carbohydrates, with resultant hyperglycemia. Factors that increase the risk of developing gestational diabetes include:

• obesity• maternal age over 30 years• history of birthing large babies• family history of diabetes


Pregnancy Module 13

• previous, unexplained stillborn birth• previous birth with congenital defects

In order to code gestational diabetes in ICD-10-CM you need to know the following:

• trimester• associated complications• type

Pre-existing diabetes mellitus, type 2, in pregnancy, second trimester

O24.112

Unspecified pre-existing diabetes mellitus in pregnancy, second trimester

O24.312

Gestational diabetes mellitus in childbirth diet controlled

O24.420

Other pre-existing diabetes mellitus in pregnancy, second trimester

O24.812

Unspecified diabetes mellitus in preg-nancy, second trimester

O24.912

According to the guidelines, code Z79.4, Long-term (current) use of insulin, should not be assigned with codes from subcategory O24.4.

Hypertension in PregnancyGestational hypertension is the development of hyper-tension during pregnancy, after 20 weeks gestation. The hypertension resolves typically after the pregnancy ends. Hypertension during pregnancy can also lead to preeclampsia which is hypertension with proteinuria or edema or to the most severe form of hypertension which is eclampsia.

In order to code hypertension in pregnancy documenta-tion must include:

• if hypertension was pre-existing• trimester• complications

Pre-existing essential hypertension complicating pregnancy, third trimester

O10.013

Pre-existing hypertensive heart disease complicating pregnancy, third trimester

O10.113

Pre-existing hypertensive chronic kidney disease complicating pregnancy, third trimester

O10.213

Pre-existing hypertensive heart and chronic kidney disease complicating preg-nancy, third trimester

O10.313

Pre-existing hypertension with pre-eclampsia, third trimester

O11.3

Gestational edema, third trimester O12.03

Gestational proteinuria, third trimester O12.13

Gestational edema with proteinuria, third trimester

O12.23

Gestational [pregnancy-induced] hyper-tension without significant proteinuria, third trimester

O13.3

Mild to moderate pre-eclampsia, third trimester

O14.03

Severe pre-eclampsia, third trimester O14.13

Codes from Chapter 15 (O00-O99A) require the use of an additional code from category Z3A. Weeks of gesta-tion, to identify the specific week of the pregnancy. These codes are for use, only on the maternal record, to indicate the weeks of gestation of the pregnancy.

Code first complications of pregnancy, childbirth, and the puerperium (O00-O9A).

Weeks of gestation of pregnancy not specified

Z3A.00


Module 13 Pregnancy

Less than 8 weeks gestation of pregnancy Z3A.01

8 weeks gestation of pregnancy Z3A.08



































Greater than 42weeks gestation of pregnancy

Z3A.49

SourcesComprehensive Medical Terminology (Fourth Edition) by Betty Davis Jones.

Stedman’s Medical Dictionary, 28th edition

Bates’ Pocket Guide to Physical Examination and History Taking, Third Edition (Lynn S. Bickley-Lippincott)

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