Instructions for the Automated Classification of the Initiating and Multiple Causes of Fetal Deaths – Section IV – 2018

SECTION IV:  CLASSIFICATION OF CERTAIN ICD-10 CATEGORIES

A.      CONGENITAL CONDITIONS

The Classification does not provide congenital and acquired codes for all conditions. When no provision is made for a distinction, disregard the statement of congenital or acquired and code the NOS code.

B.      CERTAIN FETAL CONDITIONS (P000-P969)

When reported in 18a or 18b, code the following entries as indicated:

Birth weight of         2 pounds (999 gms) or under………………………………….. P070
Over 2 pounds (1000 gms) but not more than
5 ½ pounds (2499 gms)………………………………………… P071
10 pounds (4500 gms) or more……………………………….. P080

Gestation of             Less than 28 weeks………………………………………………. P072
28 weeks but less than 37 weeks…………………………….. P073
42 or more completed weeks………………………………….. P082

                             NOTE: 37-41 weeks, no code. This is a normal gestation period.

Premature labor or delivery NOS………………………………………………………… P073

When a condition classifiable to P703-P720, P722-P749 is the only cause(s) reported in 18a or 18b, code P95. If reported with other perinatal conditions, code as indexed.

C.      ILL-DEFINED AND UNKNOWN CAUSES

When any of the following terms is the only entry (or entries) on the fetal death report, code P95 everywhere terms are reported in 18a or 18b:

Cause not found                    Immediate cause unknown

Cause unknown                      Intrauterine death

Cause undetermined                 No specific etiology

Could not be determined            identified

Deadborn fetus NOS                 No specific known causes

Etiology never determined          Non-specific causes

Etiology not defined               Not known

Etiology uncertain                 Obscure etiology

Etiology unexplained               Stillborn

Etiology unknown                   Undetermined

Etiology undetermined              Uncertain

Etiology unspecified               Unclear

Fetal Death                        Unexplained cause

Fetal Demise                       Unknown

Final event undetermined           ? Cause

Immediate cause not determined     ? Etiology

“Unknown” reported in the checkbox, code P95, if no other information is on the record. If the checkbox for Unknown is marked in one section (either 18a or 18b) and there is also a term assigned to P95 reported in the other section, code P95 in both sections.

                                                           

 18a.  INITIATING CAUSE/CONDITION

 Unknown:  Y

 18b. OTHER SIGNIFICANT CAUSES OR CONDITIONS

 Maternal Conditions/Diseases:  Undetermined

                                                           

Code 18a (Part I)P95/Code 18b (Part II) P95

Code 18a (Part I) P95, Ill-defined and Unknown Causes and code 18b (Part II) P95, Ill-defined and Unknown Causes for both reportings.

                                                           

 18a.  INITIATING CAUSE/CONDITION

 Complications of Placenta, Cord, or Membranes

 Other:  Y

 Other (specify):

 18b. OTHER SIGNIFICANT CAUSES OR CONDITIONS

 Unknown:  No specific known causes

                                                           

Code 18a (Part I) P022 P026 P029

Code 18a (Part I) P022 P026 P029, complication of placenta, cord, or membranes and leave 18b (Part II) blank since P95 is not assigned when other information is on the record.

D.      GENERAL CONCEPT REGARDING EXTERNAL CAUSES REPORTED ON FETAL DEATH REPORTS

If an external event is reported and it is the mother who received the injuries, code the appropriate P000-P049.

If an external event is reported and it is the fetus who received the injury, refer to your immediate supervisor for a code assignment. The instructions for coding external causes on regular mortality data will apply and will be assigned by the supervisor.

Refer to the following instructions on coding external causes on Fetal Death Reports.

E.       Maternal External Causes

When a complication of any type of medical care is reported, including drug therapy, surgery, or a specified type of therapy including obstetrical procedures, code the appropriate P000-P049.

Do not enter the nature of injury code, external cause code or place code. Take into consideration if the condition for which the medical care was administered is reported. If questionable, refer to Supervisor.

If any type of external event (poisonings, accident, suicide, homicide or undetermined) is reported of the mother, code to the appropriate P000-P049. Do not enter a nature of injury code, external cause code or place code.

Take into consideration where the certifier has recorded the external event and code the P000-P049 in that same position. If questionable, refer to your immediate Supervisor.

F.       Fetal Injury

When any type of medical care including drug therapy, surgery, or any other specified type of medical care is reported of the fetus, the instructions for coding external causes on regular mortality data will apply. Refer to your immediate supervisor for a code assignment.

If any type of external event or injury is reported of the fetus, the instructions for coding external causes on regular mortality data will apply. Refer to your immediate supervisor for a code assignment.