Ask the Experts: April 13, 2015

Question: As a coder who codes hospital rounds and her area of coding is Labor and Delivery my question is: When does a coder who codes Labor and Delivery also code that the baby was delivered?

Answer: Coding is specific to each individual chart and the admission associated with it. The mother should have her own chart and the baby should have its own chart. So as a inpatient coder, you would code for the mother using the codes from chapter 11 of ICD-9-CM. Codes from chapters 14 or 15 should not be assigned on the mother's chart. When you pick up the baby's chart, you would assign codes for it (separate from the mother). The codes should not come from chapter 11 of ICD-9-CM and none of the documentation from the mother's chart should be used to code for the baby. The principle diagnosis for the newborn should always be a code from the V30-V31 code category. (These codes should not be assigned on the mother's chart.) Codes from chapters 14 or 15 may also be assigned as necessary to specify any other conditions present in the newborn or occurring after birth during this stay. I recommend reviewing the official guidelines for coding and reporting especially sections I.C.11 (Chapter 11: Complications of Pregnancy, Childbirth, and the Puerperium) and section I.C.15 (Chapter 15: Newborn (Perinatal) Guidelines) for further information on coding for inpatient hospital OB and newborn cases. The official guidelines are available at this link: http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf. I enjoyed answering this question and I hope that this advice assists you.
- Christina Benjamin, MA, RHIA, CCS, CCS-P

When would it be appropriate to use procedure code 7309 AROM (artificial rupture of membranes)? I had a chart where in the delivery record it said augmented with AROM but when I look at the discharge form it only says AROM, so when I go into 3M system one time said I couldn't code it the next time it said to use 7039.

It seems that artificial rupture of membranes (AROM) was documented as a procedure to assist delivery; thus, it is appropriate to code this procedure.
- Dwan Thomas Flowers, MBA, RHIA, CCS

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