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. 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 the American Hospital Association's Coding Clinic and ICD-9-CM Coding Handbook are also included.
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. 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, or 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 the 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 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 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.
In cases when surgery is performed on the fetus, a diagnosis code from category 655 should be assigned to identify the fetal condition. A perinatal code should not be used on the mother's record to identify fetal conditions because surgery performed in utero on a fetus is to be coded as an obstetric encounter.
4. Current Conditions Complicating Pregnancy: Assign a code from subcategory 648, Other current conditions in the mother classifiable elsewhere but complicating pregnancy, childbirth or the puerperium, to identify current conditions that affects the management of the pregnancy, childbirth or the puerperium. Use additional secondary codes from other chapters to identify the conditions.
Diabetes mellitus is a significant complicating factor in pregnancy. Assign code 648.0x, Diabetes mellitus complicating pregnancy, and a secondary code from category 250, Diabetes mellitus to identify pregnant women who are diabetic. Code V58.67, Long-term (current) use of insulin, should also be assigned if the diabetes mellitus is being treated with insulin.
Gestational diabetes can occur during the second and third trimester of pregnancy in women who were not diabetic prior to pregnancy. Gestational diabetes can cause complications in the pregnancy similar to those of pre-existing diabetes mellitus. Gestational diabetes is coded to 648.8x, Abnormal glucose tolerance. Code 648.0x Diabetes mellitus complicating pregnancy and code 648.8x, Abnormal glucose tolerance should never be used together on the same record. Code V58.67, Long-term (current) use of insulin, should also be assigned if the gestational diabetes is being treated with insulin.
5. The Postpartum Period: The postpartum period begins immediately after and continues for 6 weeks following delivery. A postpartum complication is any complication occurring within this 6-week period. Chapter 11 codes may be used to describe postpartum complications after the 6-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.
6. 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 sequelae that requires care or treatment at a later date. This code may be used at any time after the initial postpartum period and is to be sequenced following the code describing the residual condition.