Tight Nuchal Cord

We have several providers in our company documenting “tight nuchal cord" when a baby is delivered, but 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 with “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.”