Coding Question of the Month: October 2019

Tight Nuchal Cord

QUESTION: We have several providers in our company documenting “tight” nuchal cord when a baby is delivered, documentation does not state “with compression” or “without compression”. Our coders have been using O69.1XX0 (L&D complicated by cord around neck, with compression) for deliveries where tight nuchal cord is documented. Does the provider have to specifically document tight nuchal cord with compression, or is tight nuchal cord sufficient enough to use the “with compression” code?

ANSWER:

While “tight” nuchal cord is not presently an official synonym for nuchal cord “with compression” under ICD-10-CM, this does not invalidate the term’s use. 
 
We recommend the following actions:

  1. Query the physicians documenting “tight nuchal cord” and verify whether or not they are using the term with the intent to mean “nuchal cord with compression.” 
  2. If the physicians confirm they are using “tight” to mean “with compression,” your coding department should work together with your facility’s Clinical Documentation Improvement Specialists to create an internal, facility-specific policy stating that “tight nuchal cord” is synonymous to “nuchal cord with compression.” 
    If the internal policy is created with this understanding, the documentation of “tight nuchal cord” ought to be sufficient to convey “nuchal cord with compression.” 

 
You might consider ICD-10-CM diagnosis code Z87.59 (Personal history of other complications of pregnancy, childbirth and the puerperium) to document a history of 4th degree perineal laceration in delivery. According to the ICD-10-CM Official Guidelines Chapter 21c4: Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring. Personal history codes may be used in conjunction with follow-up codes and family history codes may be used in conjunction with screening codes to explain the need for a test or procedure. History codes are also acceptable on any medical record regardless of the reason for visit. A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered.

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