VS-10A MEDICAL DATA SUPPLEMENTAL WORKSHEET (1989-2004)

VS-10A MEDICAL DATA SUPPLEMENTAL WORKSHEET
State of California - Health and Welfare Agency Department of Health Services
CERTIFICATE OF LIVE BIRTH - MEDICAL DATA SUPPLEMENTAL WORK SHEET
(For Hospital Use Only)

USE THE CODES CIRCLED ON THIS WORK SHEET FOR THE APPROPRIATE ENTRY IN ITEMS NUMBERED 25D AND 28A THROUGH 31 ON THE "CERTIFICATE OF BIRTH"
Item 25D. PRINCIPAL SOURCE OF PAYMENT FOR PRENATAL CARE (Circle one code only.)
01 Medicare 02 Medi-Cal (except CPS Program) 03 Workers' compensation 04 Title V (MCH funds) 05 Other government programs 06 Blue Cross/Blue Shield 07 Private insurance company 08 Health maintenance organization/prepaid health plan	09 Self pay 10 No charge 11 Other nongovernment programs 12 Medical indigent 13 Medi-Cal CPS Program 00 No prenatal care 99 Unknown
Item 28A. METHOD OF DELIVERY (Circle up to three codes.) Allowable code combinations are: 03 and 04, 04 and 05, 04 and 06, 05 and 06; and 04, 05, and 06.
01 Cesarean section - primary 02 Cesarean section - repeat 03 Vaginal birth - spontaneous	04 Vaginal birth - after previous cesarean section 05 Vaginal birth - forceps 06 Vaginal birth - vacuum
Item 28B. EXPECTED PRINCIPAL SOURCE OF PAYMENT FOR DELIVERY (Circle one code only.)
01 Medicare 02 Medi-Cal 03 Workers' compensation 04 Title V (MCH funds) 05 Other government programs 06 Blue Cross/Blue Shield 07 Private insurance company 08 Health maintenance organization/prepaid health plan	09 Self pay 10 No charge 11 Other nongovernment programs 12 Medical indigent 00 Medically unattended birth 99 Unknown
Item 29. COMPLICATIONS AND PROCEDURES OF PREGNANCY AND CONCURRENT ILLNESSES (Circle up to 16 codes 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 (Circle up to nine codes 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 (Circle codes on reverse.)

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

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

Updated November 12, 2004 by RL Williams

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