ICD-10-CM Official Guidelines for Coding and Reporting
FY 2019
Page 5 of 120
k. Puerperal sepsis ..................................................................................................................... 65
l. Alcohol, tobacco and drug use during pregnancy, childbirth and the puerperium............... 65
m. Poisoning, toxic effects, adverse effects and underdosing in a pregnant patient .................. 66
n. Normal Delivery, Code O80 ................................................................................................. 66
o. The Peripartum and Postpartum Periods............................................................................... 67
p. Code O94, Sequelae of complication of pregnancy, childbirth, and the puerperium ........... 67
q. Termination of Pregnancy and Spontaneous abortions ........................................................ 68
r. Abuse in a pregnant patient................................................................................................... 68
16. Chapter 16: Certain Conditions Originating in the Perinatal Period (P00-P96) ..................... 69
a. General Perinatal Rules......................................................................................................... 69
b. Observation and Evaluation of Newborns for Suspected Conditions not Found ................. 70
c. Coding Additional Perinatal Diagnoses ................................................................................ 71
d. Prematurity and Fetal Growth Retardation ........................................................................... 71
e. Low birth weight and immaturity status ............................................................................... 71
f. Bacterial Sepsis of Newborn ................................................................................................. 72
g. Stillbirth ................................................................................................................................ 72
17. Chapter 17: Congenital malformations, deformations, and chromosomal abnormalities (Q00-
Q99) ........................................................................................................................................ 72
18. Chapter 18: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere
classified (R00-R99) ............................................................................................................... 73
a. Use of symptom codes .......................................................................................................... 73
b. Use of a symptom code with a definitive diagnosis code ..................................................... 73
c. Combination codes that include symptoms .......................................................................... 73
d. Repeated falls ........................................................................................................................ 73
e. Coma scale ............................................................................................................................ 73
f. Functional quadriplegia ........................................................................................................ 74
g. SIRS due to Non-Infectious Process ..................................................................................... 74
h. Death NOS ............................................................................................................................ 75
i. NIHSS Stroke Scale .............................................................................................................. 75
19. Chapter 19: Injury, poisoning, and certain other consequences of external causes (S00-T88)
75
a. Application of 7
th
Characters in Chapter 19 ......................................................................... 75
b. Coding of Injuries ................................................................................................................. 76
c. Coding of Traumatic Fractures ............................................................................................. 77
d. Coding of Burns and Corrosions........................................................................................... 78
e. Adverse Effects, Poisoning, Underdosing and Toxic Effects ............................................... 80
f. Adult and child abuse, neglect and other maltreatment ........................................................ 83
g. Complications of care ........................................................................................................... 83
20. Chapter 20: External Causes of Morbidity (V00-Y99) ........................................................... 85
a. General External Cause Coding Guidelines ......................................................................... 86
b. Place of Occurrence Guideline ............................................................................................. 87
c. Activity Code ........................................................................................................................ 87
d. Place of Occurrence, Activity, and Status Codes Used with other External Cause Code .... 88
e. If the Reporting Format Limits the Number of External Cause Codes .............................. 88
f. Multiple External Cause Coding Guidelines ........................................................................ 88
g. Child and Adult Abuse Guideline ......................................................................................... 89
h. Unknown or Undetermined Intent Guideline ....................................................................... 89