ICD-10 Coding for Shoulder Dystocia(O66.0)
Complete ICD-10-CM coding and documentation guide for Shoulder Dystocia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Shoulder Dystocia
Key Information: ICD-10 code for shoulder dystocia
Essential facts and insights about Shoulder Dystocia
Primary ICD-10-CM Code for shoulder dystocia
Decision Criteria
clinical Criteria
- Presence of documented maneuvers like McRoberts or suprapubic pressure
documentation Criteria
- Documented time from head delivery to body delivery
Applicable To
- Shoulder dystocia
Excludes
- Obstructed labor due to shoulder presentation (O64.4)
Clinical Validation Requirements
- Documentation of obstetric maneuvers such as McRoberts, suprapubic pressure
- Time from head delivery to body delivery
- Neonatal injuries like Erb's palsy
Code-Specific Risks
- Incorrectly coding for 'tight shoulders' without proper documentation
- Missing documentation of maneuvers
Coding Notes
- Ensure maneuvers are documented to support the use of O66.0.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Shoulder Dystocia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code O66.0.
Impact
Clinical: Leads to inaccurate clinical records., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims due to insufficient documentation.
Mitigation Strategy
Use checklists to ensure all maneuvers are documented.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding standards., Data Quality: Inaccurate clinical data affecting patient records.
Mitigation Strategy
Ensure documentation explicitly states 'shoulder dystocia' and lists maneuvers used.
Impact
Lack of documentation for maneuvers used during shoulder dystocia.
Mitigation Strategy
Implement standardized documentation templates and training.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Shoulder Dystocia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Shoulder Dystocia
Use these documentation templates to ensure complete and accurate documentation for Shoulder Dystocia. These templates include all required elements for proper coding and billing.
Shoulder Dystocia during Delivery
Specialty: ObstetricsRequired Elements
- Time of head delivery
- Time of shoulder delivery
- Maneuvers used
- Neonatal status
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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