Ask a coder to code a pregnancy chart and one can expect mixed emotions depending on which coder is asked. Often, a coder either loves or hates to code pregnancy charts. For coders who lean toward the dislike of pregnancy coding, they often feel lost and confused with what they should be looking for to code. Understanding what pregnancy conditions to code and which fifth digit to use is often perplexing.
A coder's job is to read a patient's chart and decipher all of the diagnoses and procedures for the patient's admission or visit. Pregnancy coding can provide challenges as to which conditions to code, but the coding guidelines offers assistance, so let's look at these.
General Pregnancy Guidelines
- Pregnancy codes take precedence over all other codes in ICD-9-CM.
- It is up to the physician to state the pregnancy is NOT being affected by a specific condition.
- Do not code newborn codes on the mother's chart or pregnancy codes on a newborn's chart.
- When a delivery occurs, a code from V27.0-V27.9 should be used as a secondary diagnosis to show the outcome of delivery.
The Principal or First Diagnosis
For routine outpatient prenatal visits when there is no complication, the coder should code the first listed diagnosis to V22.0, supervision of normal pregnancy or V22.1, supervision of other normal pregnancy. These codes are not to be used with any Chapter 11 codes.
If a patient is noted to be high risk, use a code from category V23 for routine outpatient visits. When a patient is admitted but does not deliver, the principal diagnosis should be the complication that required the patient to be admitted. If the patient does deliver, the principal diagnosis should correspond with the main condition or complication of the delivery.
For Cesarean sections, if the patient is admitted for the reason the Cesarean is performed, code that reason as the principal diagnosis. Should the patient be admitted for a different reason, and a Cesarean is performed, code the condition for which the patient is admitted.
Often coders do not know how to use the pregnancy fifth digits correctly, so this equals coding errors. The fifth digit 0 (zero), unspecified as to episode of care or not applicable, is used when nothing is known about the status of the pregnancy. Fifth digit 0 (zero) is rarely used.
The fifth digit 1 is used when a mother comes in and delivers during that admission, and the mother may or may not have antepartum conditions. Fifth digit 2 is used when a mother delivers on that admission, and a complication occurs after the baby is delivered (e.g., postpartum hemorrhage). Fifth digits 1 and 2 can be used on the same admission. For example, a patient is admitted for a Cesarean section due to decreased fetal movement. Immediately following the Cesarean section with the delivery of the single, live-born baby, the patient develops postpartum hemorrhage, which the doctor is able to get under control. The diagnosis codes for this episode would be 656.31, 666.2, V27.0.
Fifth digit 3 is used when a condition is being treated before the admission for delivery (i.e., antepartum). Fifth digit 4 is used for postpartum complications after the mother goes home. Fifth digit 4 can be used up until six weeks post delivery. Unlike the fifth digits 1 and 2, the fifth digit 3 cannot be used with any other fifth digit. For example, if a patient is seen at the doctor's office at seven months pregnant with anemia and pregnancy-induced hypertension, the codes are 648.23, 642.33, and 285.9. In addition, the fifth digit 4 cannot be used with any other fifth digit.
Normal Delivery (650)
Before discussing how to code pregnancies with complications, let's look at what constitutes a normal delivery. First, let's clarify that normal delivery is referring to the diagnosis code 650, and not a procedure code. Code 650 can only be used when there is a full-term, cephalic, single, live-born infant born with minimal or no assistance. When using the code 650, the following procedures may be used: other manually assisted delivery, fetal monitoring, epidural, induction of labor by artificial rupture of membranes, episiotomy and other artificial rupture of membranes at the time of delivery. The only outcome of delivery code used with code 650 is V27.0. No other code from the code range of 630-676 can be used with code 650. Should a patient be treated earlier in pregnancy for a condition, but the condition has resolved and is no longer present, the code 650 can still be used.
When people think of complications, they often picture something very bad happening, which can occur; however, complications in pregnancy can range from the mother smoking during pregnancy to perineal lacerations occurring in delivery to the worst-case scenario, death. The key to understanding coding complications is to determine if the condition is still present at the time of an admission or visit. The next step is to know a code from subcategory 648.x is used to represent a specific pregnancy complication; in addition, a code from a different chapter is used to signify the complication.
When a pregnant woman is admitted with a HIV-related illness, the principal diagnosis is 647.6x, other specified infectious and parasitic diseases in the mother classifiable elsewhere, but complicating pregnancy, childbirth or the puerperium. An additional code of 042 is assigned as a secondary diagnosis followed by a code for the HIV-related condition. Codes 647.6x and V08 are used when a patient with an asymptomatic HIV infection status is admitted during pregnancy, childbirth or the puerperium.
When coding diabetes in pregnancy, first the determination needs to be made if the diabetes is gestational or if the patient's diabetes predates the pregnancy. If the patient has gestational diabetes, code 648.8x, abnormal glucose tolerance. If the diabetes is pre-existing, the code 648.0x is used with an additional code for the type of diabetes (category 250 or 249). Codes 648.0x and 648.8x cannot be used on the same record. If the diabetes is insulin dependent, apply an additional code for the long-term use of insulin (V58.67).
Therefore, when coding pregnancies, remember the doctor has to state if a condition is not affecting the pregnancy; otherwise, the coder must assume that it does. Also, remember pregnancy codes take precedence over all other chapter codes. Review the documentation in the history and physical and the delivery report to ensure all conditions that have a current impact on the pregnancy and/or delivery are captured and coded.
This month's column has been prepared by Meredith McCollum, an ICD-10-CM/PCS AHIMA Certified Trainer and coding educator with Precyse (www.precyse.com), which provides services and technologies that capture, organize, secure and analyze healthcare data and transform it into actionable information, supporting the delivery of quality patient care and optimizing operating performance. McCollum's position is dedicated to providing ICD-9 and ICD-10 education to both internal colleagues, as well as clients based across the U.S. She also is an adjunct professor for DeVry University where she not only teaches ICD-9 and ICD-10, but also develops classes for their nationwide Health Information Technology Program.
Take the quiz and test your knowledge on page 2.