ICD-10 Code
International Classification of Diseases, 10th Revision
Mar 26, 2017

Procedure Terms used in “Obstetrics”

Obstetrics procedure codes have a first character value of “1”. The second character value for body system is Pregnancy. The root operations Change, Drainage, Extraction, Insertion, Inspection, Removal, Repair, Reposition, Resection and Transplantation are used in the obstetrics section, and have the same meaning as in the medical and surgical section. The obstetrics section also includes two additional root operations, Abortion and Delivery, defined below:

  • Abortion: Artificially terminating a pregnancy
  • Delivery: Assisting the passage of the products of conception from the genital canal
A cesarean section is not its own unique root operation, because the underlying objective is Extraction (i.e., pulling out all or a portion of a body part). The body part values in the obstetrics section are:
  • Products of conception
  • Products of conception, retained
  • Products of conception, ectopic

The obstetrics section includes procedures performed on the products of conception only; procedures on the pregnant female are coded in the medical and surgical section (e.g., episiotomy). The term “products of conception” refers to all physical components of a pregnancy, including the fetus, amnion, umbilical cord and placenta. There is no differentiation of the products of conception based on gestational age. Thus, the specification of the products of conception as a zygote, embryo or fetus, or the trimester of the pregnancy, is not part of the procedure code but can be found in the diagnosis code.

The fifth character specifies approaches as defined in the medical and surgical section. The sixth character is used for devices such as fetal monitoring electrodes. Qualifier values are specific to the root operation, and are used to specify the type of extraction (e.g., low forceps, high forceps, low cervical cesarean, etc.), the type of fluid taken out during a drainage procedure (e.g., amniotic fluid, fetal blood, etc.) or the body system of the products of conception on which a repair was performed.


Terms for Obstetrics

Abortion
Artificially terminating a pregnancy
Change
Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane

All CHANGE procedures are coded using the approach EXTERNAL

Delivery
Assisting the passage of the products of conception from the genital canal
Drainage
Taking or letting out fluids and/or gases from a body part

The qualifier DIAGNOSTIC is used to identify drainage procedures that are biopsies

External
When used as Approach
Procedures performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane
Extraction
Pulling or stripping out or off all or a portion of a body part by the use of force

The qualifier DIAGNOSTIC is used to identify extraction procedures that are biopsies

Insertion
Putting in a nonbiological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part
Inspection
Visually and/or manually exploring a body part

Visual exploration may be performed with or without optical instrumentation. Manual exploration may be performed directly or through intervening body layers

Open
When used as Approach
Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure
Percutaneous
When used as Approach
Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure
Percutaneous Endoscopic
When used as Approach
Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure
Removal
Taking out or off a device from a body part, region or orifice

If a device is taken out and a similar device put in without cutting or puncturing the skin or mucous membrane, the procedure is coded to the root operation CHANGE. Otherwise, the procedure for taking out a device is coded to the root operation REMOVAL

Repair
Restoring, to the extent possible, a body part to its normal anatomic structure and function

Used only when the method to accomplish the repair is not one of the other root operations

Reposition
Moving to its normal location, or other suitable location, all or a portion of a body part

The body part is moved to a new location from an abnormal location, or from a normal location where it is not functioning correctly. The body part may or may not be cut out or off to be moved to the new location

Resection
Cutting out or off, without replacement, all of a body part
Transplantation
Putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part

The native body part may or may not be taken out, and the transplanted body part may take over all or a portion of its function

Via Natural or Artificial Opening
When used as Approach
Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure
Via Natural or Artificial Opening Endoscopic
When used as Approach
Entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure
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When ICD 10 was implemented on October 1, 2015, it did not affect physicians', outpatient facilities', and hospital outpatient departments' use of CPT codes on Medicare Fee-For-Service claims. Providers should continue to use CPT codes to report these services.