This month's CCS Prep! column reviews coding guidelines for obstetric and newborn coding. The review is for ICD-9-CM diagnosis coding issues only and excludes coding of abortions. Obstetric and newborn coding was chosen as our first condition-specific topic based upon requests from readers. If you would like us to dedicate an article on a specific topic or area, please e-mail your request to firstname.lastname@example.org.
Portions of the ICD-9-CM Official Guidelines for Coding and Reporting focusing on obstetrics and newborns are addressed here. However, it is important that you review the guidelines yourself after reading this article and before taking the quiz below. Guidelines found in AHA's Coding Clinic and ICD-9-CM Coding Handbook are also included.
Obstetric Coding (Excluding Abortions)
Obstetric cases require codes from Chapter 11 in the range of 630 through 677, Complications of pregnancy, childbirth and the puerperium. Only when the physician specifically documents that the pregnancy is incidental to the encounter should code V22.2, Pregnant state, incidental, be used in place of any Chapter 11 codes. It is the physician's responsibility to state that the condition being treated is not affecting or is not affected by the pregnancy. Documentation in the medical record must indicate this. Codes from Chapter 11 have sequencing priority over codes from other chapters. Additional codes from other chapters may be used to further specify conditions. Codes from Chapter 11 are to be used only on the mother's record and should never be used on the newborn's record. Codes from categories 640 through 648 and 651 through 676 require fifth digits, which indicate whether the encounter is antepartum, postpartum and whether a delivery has also occurred. The fifth digit for all codes reported during the same visit should have the same fifth digit.
For routine outpatient 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 first-listed diagnosis. A code from category V23, Supervision of high-risk pregnancy, should be the first-listed diagnosis for prenatal outpatient visits for patients with high-risk pregnancies. Codes from Chapter 11 may be used in conjunction with codes from category V23, if appropriate.
An outcome of delivery code V27.0-V27.9 should be included on every mother's record when a hospital delivery has occurred. The fourth digit indicates whether the outcome is single or multiple and stillborn or liveborn. Codes from category V27 should not be assigned if the delivery occurred outside the hospital. A code from category V27 is only used for the visit in which the delivery occurred and is not used on the newborn record.
1. Selection of OB Principal or First-listed Diagnosis: When no delivery occurs, the principal diagnosis should be the complication of the pregnancy that necessitated the encounter. If more than one complication exists and all are treated or monitored, any of the complications may be sequenced first. When a delivery occurs, the principal diagnosis should correspond to the main circumstances or complication of the delivery. When there is a cesarean delivery, the principal diagnosis should identify the reason necessitating the cesarean delivery unless the reason for admission/encounter was unrelated to the reasons for the cesarean delivery.
2. Normal Delivery Code 650: Code 650 is for use in cases when a woman is admitted for a full-term normal delivery and delivers a single, healthy infant without any complications. A delivery is considered normal when it requires no or minimal assistance, with or without episiotomy, without fetal manipulation (forceps) or instrumentation of a spontaneous, cephalic, vaginal, full-term, single liveborn. Code 650 may be used if the patient had a complication at some point during her pregnancy, but the complication is not present at the time of the admission for delivery. Code 650 is always a principal diagnosis. Code 650 is not used if there is any complication. Other codes from Chapter 11 should be used instead. Additional codes from other chapters may be used with code 650 if they are not related to or are in any way complicating the pregnancy. V27.0, Single liveborn, is the only outcome of delivery code appropriate for use with 650. If there are multiple births or stillbirth, code 650 cannot be assigned.
3. Fetal Conditions Affecting the Management of the Mother: Codes from category 655, Known or suspected fetal abnormality affecting management of the mother, and category 656, Other fetal and placental problems affecting the management of the mother, are assigned only when the fetal condition is actually responsible for modifying the management of the mother. Examples of this include diagnostic studies to evaluate the abnormality or problem, additional observation, special care or termination of pregnancy. Just because a fetal condition exists does not justify the use of a code from this series.
4. The Postpartum Period: The postpartum period begins immediately after and continues for six weeks following delivery. A postpartum complication is any complication occurring within this six-week period. Chapter 11 codes may be used to describe postpartum complications after the six-week period, as long as the physician documents that the condition is pregnancy related. All postpartum complications that occur during the same admission as the delivery are identified with a fifth digit of "2." Subsequent admissions and encounters for postpartum complications are identified with a fifth digit of "4."
When the mother delivers outside the hospital prior to admission and is admitted for routine postpartum care and no complications are noted, code V24.0, Postpartum care and examination immediately after delivery, should be assigned as the principal diagnosis. A delivery code should not be used for a woman who has delivered prior to admission to the hospital. Any postpartum procedures should be coded.
5. Late Effect of Complication of Pregnancy, Childbirth and the Puerperium: Code 677, Late effect of complication of pregnancy, childbirth and the puerperium, is assigned when an initial complication of a pregnancy develops a sequelae that requires care or treatment at a later date. This code may be used at any time after the initial post-partum period and is to be sequenced following the code describing the residual condition.
Newborn Coding Guidelines
The perinatal period is defined as birth through the 28th day following birth. All clinically significant conditions noted on routine newborn examination should be coded. A condition is clinically significant if it requires: clinical evaluation; therapeutic treatment; diagnostic procedures; extended length of hospital stay; increased nursing care and/or monitoring; or has implications for future health care needs.
The perinatal guidelines listed above are the same as the general coding guidelines for "additional diagnoses," except for the final point regarding implications for future health care needs. The physician can only determine whether or not a condition is clinically significant.
1. Classification of Births: Assign a code from categories V30-V39 for liveborn infants according to type of birth. Type is defined as single or multiple. If multiple, the code further indicates whether mates are liveborn or stillborn, and fourth digits indicate where the birth occurred. For live births occurring in the hospital, the fifth digit indicates whether there was a cesarean delivery. A code from this series is assigned as a principal diagnosis and used only once on the newborn record at the time of birth. If the newborn is discharged and readmitted or transferred to another facility, a code from the V30 series is not used on the readmission or at the receiving hospital.
2. Additional Diagnoses: Codes from categories V30 through V39 indicate that a live birth occurred. Codes from categories 760-779 are assigned for all clinically significant conditions noted on examination of the newborn and only if the physician has documented the condition in the medical record. A condition is clinically significant if it meets the above guidelines. Insignificant conditions or signs or symptoms that resolve without treatment are not coded and reported. Conditions that resolve without treatment and require no work-up should not be coded. These conditions include rashes and minor jaundice.
3. Observation and Evaluation of Newborns or Infants: Assign a code from category V29, Observation and evaluation of newborns and infants for suspected conditions not found, to identify instances when a healthy newborn is evaluated for a suspected condition that is determined after study not to be present. A code from category V29 may be used as a secondary code along with a code from categories V30-V39. It may also be assigned as a principal code for readmissions or encounters when the V30- V39 code no longer applies. Codes from category V29 are used only for healthy newborns and infants when no condition is found after study.
4. Maternal Causes of Perinatal Morbidity: Codes from categories 760-763, Maternal causes of perinatal morbidity and mortality, are assigned only to the newborn record and only when the mother's condition has actually affected the fetus or newborn. The fact that the mother has an associated medical condition or experiences some complication of pregnancy, labor or delivery does not justify the assignment of codes from these categories.
5. Congenital Anomalies: Assign an appropriate code from categories 740-759, Congenital anomalies, as a secondary diagnosis when a specific abnormality is diagnosed. Congenital anomalies may also be the principal or first-listed diagnosis for admissions/encounters subsequent to the newborn admission. Such abnormalities may occur as a set of symptoms or multiple malformations. A code should be assigned for each manifestation of the syndrome if the syndrome is not specifically indexed in ICD-9-CM.
6. Prematurity and Fetal Growth Retarda-tion: Codes from category 764 and subcategories 765.0 and 765.1 should not be assigned based solely upon recorded birth weight or estimated gestational age, but on the attending physician's clinical assessment of maturity of the infant. Because physicians may utilize different criteria in determining prematurity, do not code the diagnosis of prematurity unless the physician documents this condition in the medical record. A code from the new subcategory 765.2, Weeks of gestation, should be assigned as an additional code with category 764 codes and codes from sub-categories 765.0 and 765.1 to specify weeks of gestation as documented by the physician. Subcategory 765.2 is new for Oct. 1, 2003.
After reviewing the material, take the following quiz:
1. Code 650 for normal delivery may not be applied when:
a. the presentation is other than cephalic or vertex
b. the gestation is less than full term
c. an episiotomy is performed
d. a and b
e. all of the above
2. A five-month pregnant female is diagnosed with iron-deficiency anemia and is sent to the clinic for a transfusion.
b. 280.9, V22.2
c. 648.23, 280.9
3. A woman is readmitted one week after delivery with a diagnosis of delayed hemorrhage due to retained placental fragments.
a. 666.24, 623.8
4. A woman is admitted for delivery and is given prophylactic antibiotics because she has mitral valve prolapse. The physician does not document the mitral valve prolapse as a complication of the pregnancy or a condition complicating the pregnancy.
a. 650, 424.0
c. 648.61, 424.0
5. Newborn twin girls delivered at 35 weeks, weighing 850 grams for twin A and 900 grams for twin B. Both were diagnosed with extreme immaturity. Both would be assigned:
a. V31.00, 765.03
b. V31.00, 765.03, 765.28
c. V31.00, 765.13
d. V31.00, 765.13, 765.28
6. A full-term live birth child is born to a chronic alcoholic mother and is placed in the neonatal intensive care unit for observation for possible alcohol-related problems. None found.
a. V30.00, 760.71
b. V30.00, V29.8
c. V30.00, 779.8
7. A healthy newborn delivered via cesarean section is kept in the hospital for eight days because of maternal complications. The complications had no effect on the newborn.
a. V30.01, V65.0, V20.1
b. V30.01, V65.0
c. V30.01, V20.1
8. Is it appropriate to code 760.75, Noxious influence affecting fetus via placenta or breast milk, cocaine, when a baby is born to a cocaine abuser/dependent mother and no specified manifestation is documented in the newborn record?
This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, manager of clinical HIM services, HSS Inc. (www.hssweb.com), which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.
Coding Clinic is published quarterly by the American Hospital Association.
CPT is a registered trademark of the American Medical Association.
Answers to CCS PREP!
1. d: Code 650 may not be assigned if the presentation is other than cephalic or vertex or if the gestation is less than full term. It is appropriate to use code 650 if an episiotomy is performed.
2. c: Codes 648.23, 280.9 are both assigned. 648.23 is assigned because it is complicating the pregnancy, requiring transfusion. Code 280.9 is assigned to provide greater specificity as to the type of anemia.
3. c:.666.24 is the correct answer because it indicates delayed postpartum hemorrhage due to retained placenta. Only code 666.24 is required because it completely explains the circumstances.
4. c: 648.61 and 424.0 are both assigned because 648.61 identifies the pregnancy complicated by other cardiovascular disease. Code 424.0 identifies the specific condition. It is the physician's responsibility to indicate if a condition is not complicating or is not complicated by the pregnancy. Failure to document this means that the condition is then coded as a pregnancy complication.
5. b: V31.00 is assigned to indicate twin with liveborn mate; 765.03 is assigned for extreme immaturity with weight between 750-999 grams; and 765.28 indicates 35 weeks gestation. Even though the twins were 35 weeks gestation, the documentation in the medical record indicates extreme immaturity.
6. b: Codes V30.00 for single newborn and V29.8 for observation for other specified condition are assigned. No alcohol-related conditions were found on observation.
7. c: Code V30.01 is assigned for single newborn delivered by cesarean section. Only one additional code, V20.1, is used to indicate a healthy infant receiving care.
8. b: No. Do not code conditions from category 760 unless the mother's condition has actually affected the fetus or newborn. In this instance, it did not. <% footer %>