We will be discussing the importance of obstetrical, as well as newborn coding guidelines in this issue of CCS Prep! There are a few differences in these guidelines as compared to the general inpatient and outpatient guidelines we have discussed in the previous issues of CCS Prep! If you are a coding professional who is not familiar with obstetrical and newborn coding or the guidelines, take the time now to become acquainted with their requirements. Faye Brown's ICD-9-CM Coding Handbook with Answers also has information in this area in Chapters 20-23.
The guidelines for obstetrical coding are contained in section 5 of The Official ICD-9-CM Guidelines for Coding and Reporting. They are further divided into the following areas:
General Obstetrical Guidelines
5.1 A. Obstetrical cases require codes from chapter 11, codes in the range of 630-677, Complications of Pregnancy, Childbirth and the Puerperium. Should the physician document that the pregnancy is incidental to the reason for the encounter/admission, then code V22.2 should be used in place of any chapter 11 codes. The important thing to remember is that it is the physician's responsibility to state that the condition being treated is not affecting the pregnancy. Unless the physician documents this, the coder should assume that the condition is a pregnancy complication in obstetrical cases. For example, if the obstetrical patient has delivered this admission, and the physician has documented anemia, code 648.2X would be assigned first, followed by 285.9. The physician would have to document "anemia unrelated to pregnancy" to assign only 285.9 without the obstetrical code. We find that it is rare that a physician will document in this manner unless prompted or education has been provided.
B. Chapter 11 codes (630-677) have sequencing priority over codes listed from other chapters. Additional codes from other chapters can be used in conjunction with chapter 11 codes to further specify conditions if necessary. They are listed as secondary diagnoses. In the example from A above, the 648.2X code is sequenced first, followed by the code for anemia, 285.9. Code 285.9 is used to show the type of anemia.
C. Chapter 11 codes are used only on the maternal record, never on the newborn record. Be careful about this. I have seen some coders forget that they had the newborn record and start to code obstetrical conditions. This sometimes happens because nurses will frequently copy maternal record information or use carbon copies of the maternal record and place them on the newborn records.
D. An outcome of delivery code, V27.0-V27.9 should be included on every maternal record when a delivery has occurred. They are used once on the delivery record, and not on subsequent cases. If your facility has a policy of not reporting this code, you should be aware of this guideline for the examinations. Be sure to use outcome of delivery codes on the examinations.
5.2 A. The circumstances of admission or encounter govern the selection of the principal diagnosis.
B. When no delivery occurs, the principal diagnosis should be the complication of pregnancy code that necessitated the encounter. If more than one complication exists and all are treated and monitored, any of the obstetrical complications may be sequenced first. Remember, physicians must document that conditions are unrelated to the pregnancy to negate the obstetrical complication codes.
C. When a delivery occurs, the principal diagnosis should correspond to the main circumstances or complication of the delivery. For cesarean deliveries, the reason for the cesarean section should be listed first unless the reason for admission was unrelated to the cesarean delivery.
D. For routine prenatal visits when no complications are present, codes V22.0 (supervision of normal first pregnancy) and V22.1 (supervision of other normal pregnancy) should be used as the principal diagnosis. These codes should not be used in conjunction with chapter 11 codes. Be sure not to use both a V22.X code and obstetric code on the same inpatient or outpatient record, unless the V22.X code is an admission code.
E. For prenatal outpatient visits for patients with high-risk pregnancies, a code from category V23 (supervision of high-risk pregnancy) should be used as the principal diagnosis. Secondary chapter 11 codes can be used in conjunction with these codes if appropriate. Be sure to check the excludes notes under both codes to be sure you are using these correctly.
5.3 Fifth Digits. Categories 640-648 and 651-676 have required fifth digits to indicate antepartum, postpartum or if delivery has occurred. The appropriate fifth digits for each obstetrical code are listed under the code and should all be consistent with each other. ( i.e., all delivery fifth digits must be listed if a delivery).
5.4 Fetal Conditions. Codes from category 655 and 656 are assigned only when the fetal condition is actually responsible for modifying the management of the mother. The fact that the fetal condition exists does not justify assigning a code from this series to the mother's record.
5.5 Normal Delivery. Code 650 is assigned only when there is no other complication, either antepartum or postpartum, and a single, healthy infant is delivered. Code 650 can be used if the patient had complications at some point in the pregnancy, but does not have any presently. Code 650 is always the principal diagnosis, and no other code from chapter 11 should be used with it. V27.0 is the only outcome code allowed with 650. Presentation at delivery can be only head or occipital (terms such as ROA, LOA, ROP, LOP and vertex describe occipital presentation).
5.6 A delivery procedure code (such as 73.6, episiotomy or 73.59 for manually assisted delivery) is not used for a woman who delivered prior to admission to the hospital. Any postpartum repairs such as laceration sutures should be coded.
5.7 A. The postpartum period begins immediately after delivery and continues for six weeks following delivery. A postpartum complication is any complication occurring within this six-week period. Should the physician document a postpartum condition that is pregnancy related, codes from chapter 11 are assigned with fifth digits of "2" or "4." When the mother delivers outside the hospital prior to admission and is admitted for routine postpartum care and no complications exist, code V24.0 (Postpartum care and examination) should be assigned as the principal diagnosis.
5.8 Abortions (See the official guidelines for a full explanation). Abortion codes are 634-637. Use fifth digit 1, incomplete when all of the products of conception have not been expelled and fifth digit 2, complete, if they have been, prior to the episode of care. Codes 640-648 and 651-657 can be used as additional codes, use fifth digit 3. Codes 660-669 cannot be used.
Code 639 is to be used for all complications of abortion. They cannot be used with codes 634-638. If attempted termination of pregnancy with liveborn fetus, assign 644.21. Early onset of delivery, with V27 series code. Retained products of conception following spontaneous abortion are coded to the 634.X1 series, using fifth digit of 1.
5.9 Late effects of complication of pregnancy is coded to 677 and is used any time after the initial six-week postpartum period. It is sequenced following the code describing the sequelae of the complication.
General Newborn Guidelines
The newborn/neonatal coding guidelines are contained in section 6 of the Official Coding Guidelines for Coding and Reporting.
6.0 The time period designated for newborns is birth through the 28th day following birth. This definition is important when assigning codes in the 760-779. However, the ICD-9-CM includes note for this section states that conditions that have their origin in the perinatal period, even though death or morbidity occurs later, can be assigned to this code range. For example, bronchopulmonary dysplasia originating in the perinatal period is coded to 770.7 in an adult patient (Coding Clinic, Nov-Dec, 1986 pp. 11-12). As a general rule, all clinically significant conditions noted on routine newborn examination should be coded. A condition is clinically significant if it requires the following: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring; or has implications for future health care needs. (This final requirement is an exception to the general guidelines for coding secondary diagnoses on inpatient cases.)
6.1 Assign a code from categories V30-V39 when coding the birth of an infant as principal diagnosis. It is assigned only once to a newborn, at the time of birth only. If the newborn has been transferred from another institution, the V30-V39 series of codes would be used by the first hospital, but not by the second hospital. In this instance, the reason for the transfer would be coded as the principal diagnosis at the second hospital.
6.3 Assign V29 series code for observation and evaluation of newborns and infants for suspected conditions not found. This category is to be used when a condition has been determined not to be present. If the newborn is exhibiting documented signs and symptoms, code the sign or symptom and not V29. Category code V29 can be assigned when V30-V39 does not apply, and no condition is found to be present after study.
6.4 Codes from the "Maternal causes of perinatal morbidity and mortality," categories 760-763, are assigned only when the maternal condition has actually affected the fetus or newborn. Just because the mother has had a complication during the pregnancy or delivery, does not justify the assignment of codes from these categories to the newborn record. For example, if the mother had been treated for cocaine abuse during pregnancy, delivers the newborn, and the newborn has no signs or symptoms of cocaine withdrawal documented, then no code would be assigned from categories 760-763.
6.5 Assign the code from categories 740-759, Congenital Anomalies, when the physician has documented a specific congenital anomaly within the record.
6.6 Codes from categories 760-779 are assigned only if the physician has documented the condition in the medical record. Insignificant conditions or signs or symptoms that resolve without treatment are not coded and reported. Be careful to read all of the record information to be sure this condition has not resolved and been treated or monitored.
6.7 Codes from the categories of 764 and 765 are not assigned based on recorded birthweight or estimated gestational age alone. The attending physician must document his or her clinical assessment of the maturity of the newborn, i.e., he/she must document prematurity. Different physicians use different criteria for prematurity, so you may have a case where the newborn is premature according to the physician, but does not meet the implied guidelines under category 765.
With the obstetric and newborn guidelines reviewed, take this quick quiz to test your knowledge:
1. A patient was admitted three weeks following a delivery with a postpartum breast abscess. What diagnosis code(s) should be assigned?
b) 677, 611.0
2. A 48-year-old obstetrical patient GIII PII is admitted with cephalopelvic disproportion causing obstructed labor. The patient also has mild anemia that is treated during the admission with FeSol. A cesarean section is performed with delivery of a single live infant. The physician stated the patient's age was a factor in the delivery. Assign diagnoses codes, principal first.
a) 648.21, 285.9, 653.41, 660.11, V27.0
b) 660.11, 653.41, 648.21, 285.9,
c) 653.41, 648.21, 659.61,V27.0
3. A patient has a completely normal spontaneous delivery of a single live born infant. Thirty hours after delivery, the patient suffers from a severe postpartum hemorrhage. What code(s) is assigned?
a) 666.22, V27.0
b) 650, V27.0, 677
c) 666.22, 677, V27.0
d) 666.12, V27.0
4. A patient who is GIII, PIII, delivers twin liveborn males via C-section. The C-section was performed due to fetal bradycardia. What code(s) should be assigned?
a) 656.31, V27.0
b) 659.71, V27.2
c) 659.71, 659.41, V27.2
5. A female is admitted with pre-existing hypertension and pre-eclampsia. The patient delivers twins, one live born, one stillborn. Assign the diagnosis codes.
a) 642.01, 401.9, 651.01,V27.3
b) 401.9, 651.01, 656.41, V27.3
c) 642.71, 651.01, 656.41, 401.9, V27.3
6. Codes V20.1 and V29.0 (observation for newborn condition ruled out) can only be listed as principal diagnosis. True or False?
7. The record states 40 1/2 weeks, post dates, delivered by the MD. The coder should assign 645.01. True or False?
Coding Scenario #1
An infant is born vaginally at Happy Family Hospital, a small rural hospital. The infant is at 37 1/2 gestational weeks and weighs 2,300 grams. The attending physician examines the infant and documents "premature infant" in the record. The attending physician transfers the infant to White Cloud Hospital, which has a level III neonatology unit.
Upon arrival to White Cloud Hospital, the neonatologist examines the infant and documents the following diagnoses in the record: prematurity, jaundice in prematurity, transient tachypnea, suspected sepsis, molding of the head, syndactyly and transient hypoglycemia. The infant is treated in the NICU. The infant received phototherapy times five to treat the jaundice. In addition, the infant received oxygen treatments. Blood glucose levels were monitored throughout the stay to assess the hypoglycemia. Glucose levels were normal upon discharge. Blood cultures were negative. The infant will be brought back to the hospital in a few weeks to treat the syndactyly of the fingers with surgery so as to prevent future problems.
8. What are the correct diagnosis codes, principal listed first, for the infant's Happy Family Hospital stay?
a) 765.18, 771.8, 755.11, 774.2, 770.6,
b) V30.00, 765.18
d) V30.00, 765.18, 755.11, 774.2, 770.6,
9. What are the correct diagnosis codes, principal listed first, for the infant's White Cloud Hospital stay?
a) 765.18, 771.8, 755.11, 774.2, 770.6,
b) V30.00, 765.18, 771.8, 755.11, 774.2,
770.6, 767.3, 775.6
c) 765.18, 770.6, 775.6, 774.2, 755.11, V29.0
d) V30.00, 770.6, 775.6, 774.2, 755.11,
Coding Scenario #2
An infant is born by cesarean section in the hospital. The mother has a history of diabetes mellitus, which complicated the management of her pregnancy. In addition, the mother abused cocaine throughout her pregnancy. The infant was monitored for drug withdrawal, however no symptoms were noted and the toxicology report came back negative. ABO incompatibility was documented, but the Coomb's test was negative.
10. What are the correct diagnoses codes, principal listed first, for this scenario?
a) V30.01, 775.1, 773.1, 779.5
b) V30.01, V29.8
c) V30.01, 775.0, V29.8
d) V30.01, 779.5, 773.1 n
Patricia Maccariella-Hafey is director of education for Health Information Associates Inc., a company specializing in providing coding compliance review services, coding education and contract coding for health care facilities. The corporate office is headquartered in Pawley's Island, SC.
Coding Clinic is published quarterly by the American Hospital Association
"CPT only " 2001 American Medical Association. All Rights Reserved."
Answers: 1. c (675.14 covers the entire condition per Coding Clinic, 1995 4Q p.25);
2. b (See Coding Clinic, 1995 3Q p. 10) Pt. Is elderly mulitgravida;
3. a (bleeding
occurred after 24 hours);
4. b (See Coding Clinic 1998 1Q p. 47) (PIII indicates
the patient has given birth to 3 infants. Grand multiparity is 6 or more.);
c (401.9 is optional but specifies the type of hypertension);
6. b False. They
can be either principal or secondary. See Coding Clinic 2000 1Q page 25;
False. New code 645.11 effective Oct 2000. (See also Coding Clinic 2000 4Q p.
43) If you do not have up-to-date books, get them now!;
8. b (prematurity was
documented by the doctor, see Coding Clinic 1994, 1Q p. 12-15);
9. c (Conditions
treated or to be followed up after discharge. Molding of head was not addressed
10. b (the other conditions were not present or treated, see Coding
Clinic 1992 3Q p. 8-9)