VS-10A MEDICAL DATA SUPPLEMENTAL WORKSHEET (2005)

 



 

VS 10A (1/2005)      CERTIFICATE OF LIVE BIRTH—MEDICAL DATA SUPPLEMENTAL WORKSHEET

Use the codes on this Worksheet to report the appropriate entry in items numbered 25D and 28A through 31 on the “Certificate of Live Birth.”

Item 25D.   PRINCIPAL SOURCE OF PAYMENT FOR PRENATAL CARE  (Enter only 1 code) 

02   Medi-Cal, without CPSP Support Services

13   Medi-Cal, with CPSP Support Services

05   Other Government Programs (Federal, State, Local)

07  Private Insurance Company   

09  Self Pay

14  Other

99  Unknown 

00  No Prenatal Care

Item 28A.   METHOD OF DELIVERY   (Enter only 1 code/number under each section, separated by commas:  A,B,C,D,E)                                                                        

A. Final delivery route 

01   Cesarean—primary

11   Cesarean—primary, with trial of labor attempted

21   Cesarean—primary, with vacuum

31   Cesarean—primary, with vacuum & trial of labor attempted

02   Cesarean—repeat

12   Cesarean—repeat, with trial of labor attempted

22   Cesarean—repeat, with vacuum

32   Cesarean—repeat, with vacuum & trial of labor attempted

03   Vaginal—spontaneous

04   Vaginal—spontaneous, after previous Cesarean

05   Vaginal—forceps

15   Vaginal—forceps, after previous Cesarean

06   Vaginal—vacuum

      16   Vaginal—vacuum, after previous Cesarean

B. If mother had a previous CesareanHow many? _______
      (Enter 0 – 9, or U if Unknown)
C. Fetal presentation at birth

20   Cephalic fetal presentation at delivery

30   Breech fetal presentation at delivery

40   Other fetal presentation at delivery

90   Unknown

D. Was vaginal delivery with forceps attempted, but unsuccessful?

50  Yes          58  No          59  Unknown 

E. Was vaginal delivery with vacuum attempted, but unsuccessful?

 60  Yes          68  No          69  Unknown

       

Item 28B.   EXPECTED PRINCIPAL SOURCE OF PAYMENT FOR DELIVERY  (Enter only 1 code)

02   Medi-Cal

15   Indian Health Service

16   CHAMPUS/TRICARE

05  Other Government Programs (Federal, State, Local)

07  Private Insurance

09  Self Pay

14  Other

99  Unknown

00  Medically Unattended Birth

Item 29.   COMPLICATIONS AND PROCEDURES OF PREGNANCY AND CONCURRENT ILLNESSES

                (Enter up to 16 codes, separated by commas, for the most important complications/procedures)

01

Preeclampsia (pregnancy-induced hypertension)

02

Eclampsia (convulsions or coma)

03

Hypertension, chronic

04

Renal disease

05

Pyelonephritis

06

Anemia (hct.<30 and/or hgb.<10)

07

Cardiac disease

08

Lung disease, acute or chronic

09

Diabetes

10

Rh sensitization

11

Hemoglobinopathy

12

Uterine bleeding before labor

13

Polyhydramnios/oligohydramnios

14

Incompetent cervix (with or without cerclage)

15

Premature labor

16

Genital herpes

17

Other sexually transmitted diseases

18

Hepatitis B (acute infection or carrier)

19

Rubella

20

Tobacco use during pregnancy

 

   Codes 21, 22, and 23 apply to any previous live birth or fetal

   death (single or multiple):

21

> 4000 grams birthweight

22

<2500 grams birthweight

23

<37 weeks gestation

24

Cervical cerclage

25

Chorionic villus sampling

26

Amniocentesis

27

Electronic fetal monitoring

28

Tocolysis

29

Ultrasound

30

Other

00

None

Item 30.   COMPLICATIONS AND PROCEDURES OF LABOR AND DELIVERY 

                 (Enter up to 9 codes, separated by commas, for the most important complications/procedures)

01

Preeclampsia (pregnancy-induced hypertension)

02

Eclampsia (convulsions or coma)

03

Seizures during labor

04

Fetopelvic disproportion

05

Shoulder dystocia

06

Breech or other abnormal presentation

07

Precipitous labor (<3 hours)

08

Prolonged labor (>20 hours)

09

Other dysfunctional labor

10

Premature rupture of membrane (> 12 hours)

11

Induction of labor

12

Stimulation of labor

13

Abruptio placenta

14

Placenta previa

15

Other excessive bleeding

16

Genital herpes

17

Amnionitis/sepsis

18

Febrile (> 100 F. or >38 C.)

19

Presence of meconium, moderate/heavy

20

Cord prolapse

21

Fetal distress

22

Anesthetic complications

23

Unsuccessful attempt at vaginal birth after cesarean section

24

Maternal blood transfusion

25

Transport of mother from another facility prior to delivery

26

Amniocentesis

27

Electronic fetal monitoring

28

Tocolysis

29

Ultrasound

30

Maternal death (within 72 hours of delivery)

31

Other

00

None

Item 31.  ABNORMAL CONDITIONS AND CLINICAL PROCEDURES RELATING TO THE NEWBORN (Report codes on reverse.)

Do not enter any identification by patient name or number on this worksheet.  Discard after use.

Do not retain the worksheet in the medical records or submit with the “Certificates of Live Birth.”

 

VS-10A MEDICAL DATA SUPPLEMENTAL WORKSHEET
(REVERSE)
CERTIFICATE OF LIVE BIRTH, MEDICAL DATA SUPPLEMENTAL WORK SHEET (Continued)
(Circle up to ten codes for the most important conditions/procedures.)

Item 31. ABNORMAL CONDITIONS AND CLINICAL PROCEDURES RELATING TO THE NEWBORN
(Circle up to ten codes for the most important conditions/procedures.)

CENTRAL NERVOUS SYSTEM (CNS)

01 Anencephalus (740.0), with or without spina bifida. Include craniorachischisis (740.1) and iniencephaly (740.2).

02 Open spina bifida (741.0, 741.9). If hydrocephalus is also present, enter code 05 in addition to code 02.

03 Encephalocele (742.0).

04 Microcephalus (742.1).

05 Hydrocephalus (741.0, 742.3). If spina bifida is also present, enter code 02 in
addition to code 05.

06 Other anomalies of central nervous system (remainder of 740-742).


EYE

07 Anophthalmos (743.0).

08 Congenital cataract (743.3).

09 Coloboma (743.4). Exclude other anomalies of anterior segments.

10 Other anomalies of eye (remainder of 743).


EAR, FACE, NECK

11 Branchial clefts (cyst, sinus, and/or fistula)(744.4).

12 Other anomalies of ear, face, and/or neck
(remainder of 744).


CIRCULATORY SYSTEM

13 Truncus arteriosus (745.0).

14 Transposition of great vessels (745.1).

15 Tetralogy of Fallot (745.2).

16 Ventricular septal defect (VSD) (745.4).

17 Atrial septal defect (ASD) (745.5).

18 Endocardial cushion defects (745.6).

19 Valve stenosis and/or insufficiency
(746.0-746.6).

20 Hypoplastic left heart syndrome (746.7).

21 Other anomalies of heart (remainder of
745-746).

22 Patent ductus arteriosus (747.0).

23 Coarctation of aorta (747.1).

24 Other anomalies of circulatory system (remainder of 747).









RESPIRATORY SYSTEM

25 Choanal atresia (748.0).

26 Agenesis, hypoplasia, or dysplasia of lung (748.5).

27 Other anomalies of respiratory system
(remainder of 748).

CLEFT PALATE, LIP

28 Cleft palate (749.0).

29 Cleft lip (749.1).

30 Cleft palate with cleft lip (749.2).

DIGESTIVE SYSTEM

31 Tracheo-esophageal fistula, or esophageal
atresia or stenosis (750.3)

32 Atresia or stenosis of small intestine
(751.1).

33 Atresia or stenosis of large intestive, rectum, and/or anal canal (751.2).

34 Other anomalies of digestive system (remainder of 750-751)

GENITOURINARY SYSTEM

35 Hypospadias or epispadias (752.6).

36 Indeterminate sex or pseudohermaphroditism (752.7).

37 Other anomalies of genital system (remainder of 752).

38 Renal agenesis (753.0).

39 Cystic kidney disease (753.1).

40 Congenital ureteral obstruction (753.2).

41 Exstrophy of urinary bladder (753.5)

42 Other anomalies of urinary system (remainder of 753.)

MUSCULOSKELETAL DEFORMITIES

43 Hip dislocation with CNS (754.3).

44 Talipes (754.5-754.7).

45 Preaxial polydactyly (accessory thumbs) (part of 755.0). Exclude skin tags.

46 Other polydactyly (remainder of 755.0). Exclude skin tags.

47 Syndactyly of fingers and/or toes (755.1).

48 Missing fingers and/or toes (part of 755.2; part of 755.3).

49 Other missing extremity, partial or complete (remainder of 755.2-755.4).

50 Craniosynostosis (part of 756.0). Exclude acrocephaly, hypertelorism, and oxycephaly

51 Chondrodystrophy (756.4).






MUSCULOSKELETAL DEFORMITIES
(Continued)

52 Anomalies of diaphragm (756.6).

53 Gastroschisis, exomphalos, or omphalocele
(756.7, 551.1, 552.1, 553.1). Exclude simple umbilical hernia.

54 Other anomalies of musculoskeletal system (remainder of 754-756).

55 SKIN, NAILS, HAIR
(757.0-757.9).

56 VISIBLE AMNIOTIC BANDS (Amniotic band syndrome affecting the child) (658.8).

CHROMOSOMAL ANOMALIES

57 Down's syndrome (trisomy 21) (758.0).

58 Other autosomal trisomies (758.1, 758.2, 758.5). Include Patau's syndrome(trisomy 13, Edwards' syndrome (trisomy 18), and other autosomal trisomies.

59 Abnormalities of sex chromosomes (758.6-758.8). Include Turner's syndrome and Klinefelter's syndrome.

60 Other conditions due to chromosome anomalies (remainder of 758).

61 MULTIPLE NONSPECIFIC ANOMALIES
(759.7).

62 OTHER AND UNSPECIFIED
CONGENITAL ANOMALIES
(remainder of 759).

OTHER CONDITIONS AND PROCEDURES

63 Anemia (hct. <39 and/or hgb. <13): due to Rh antibodies (730.0); due to ABO antibodies (773.1) due to fetal blood loss (776).

64 Fetal alcohol syndrome (part of 760.7).

65 Drug withdrawal syndrome (779.5).

66 Birth injury, with or without specific site (767.0-767.9).

67 Hyaline membrane disease or RDS (769).

68 Meconium aspiration syndrome (770.1).

69 Congenital rubella syndrome (771.0).

70 Seizures (779.0).

71 Assisted ventilation <30 min. (Procedure; no ICD 9 code).

72 Assisted ventilation >30 min.
(Procedure; no ICD 9 code).

73 Neonatal Intensive Care Unit (NICU) (>24 hours; <24 hours if infant died).

74 Transfer of newborn to another facility. (Procedure; no ICD 9 code).

75 Other

00 None

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