COBGC ICD-10 Coding for OB/GYN 3 — Questions and Answers
Question 1: A patient delivers a single liveborn infant at 39 weeks via uncomplicated spontaneous vaginal delivery. Which code set is correct?
- O80, Z3A.39, Z37.0 (Correct answer)
- O82, Z3A.39, Z37.0
- O80, Z3A.39, Z37.1
- O84.0, Z3A.39, Z37.0
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.
Question 2: The outcome of delivery code from category Z37 is:
- Used only for cesarean deliveries, not vaginal deliveries
- Always assigned as a secondary code on the maternal delivery record (Correct answer)
- Assigned to the newborn's medical record to document birth status
- Optional and not routinely required for delivery encounters
Correct 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.
Question 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?
- O82 – Encounter for cesarean delivery without indication
- O32.1XX0 – Maternal care for breech presentation, single fetus (Correct answer)
- O80 – Encounter for full-term uncomplicated delivery
- O34.219 – Maternal care for unspecified scar from previous cesarean delivery
Correct 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.
Question 4: A patient at 35 weeks has premature rupture of membranes (PROM) with labor beginning within 24 hours. Which ICD-10-CM code applies?
- O42.00 – PROM, onset of labor within 24 hours, unspecified weeks of gestation
- O42.013 – Preterm PROM, onset of labor within 24 hours, third trimester (Correct answer)
- O42.10 – PROM, onset of labor after 24 hours, unspecified weeks of gestation
- O42.113 – Preterm PROM, onset of labor after 24 hours, third trimester
Correct 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.
Question 5: A patient at 34 weeks has complete placenta previa with active hemorrhage. Which ICD-10-CM code is correct?
- O44.10 – Complete placenta previa with hemorrhage, unspecified trimester
- O44.13 – Complete placenta previa with hemorrhage, third trimester (Correct answer)
- O44.03 – Complete placenta previa without hemorrhage, third trimester
- O44.33 – Partial placenta previa with hemorrhage, third trimester
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.
Question 6: Puerperal sepsis following delivery is coded as:
- O85 – Puerperal sepsis (Correct answer)
- O86.0 – Infection of obstetric surgical wound, superficial incision
- A41.9 with Z87.59 – Sepsis, unspecified organism, with personal history
- O90.89 – Other complications of the puerperium, not elsewhere classified
Correct 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.
Question 7: A second-degree perineal laceration occurring during vaginal delivery is coded as:
- O70.0 – First degree perineal laceration during delivery
- O70.1 – Second degree perineal laceration during delivery (Correct answer)
- O70.2 – Third degree perineal laceration during delivery
- O71.0 – Rupture of uterus before onset of labor
Correct 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.
COBGC ICD-10 Coding for OB/GYN 3
A patient delivers a single liveborn infant at 39 weeks via uncomplicated spontaneous vaginal delivery.
Which code set is correct?