Question

Coding for deliveries requires careful review of the medical record and determination of the codes assigned to the mother’s medical record and those codes assigned to the newborn record.

VBAC and Cesarean Deliveries   

EQ: Describe the key components you need to identify to code these cases

Answer 1

Understanding obstetric/maternity care is critical for success in coding and billing for these services. Obstetric/maternity care is broken down into three separate areas:

• Antepartum care

• Delivery of the baby(ies)

• Postpartum care

The AMA has developed maternity CPT codes that encompass services in a total obstetrical/maternity package. For outpatient coders, this allows them to bill for the antepartum, the delivery, and postpartum care using one CPT code. However inpatient coders don’t have that luxury. ICD-9-CM does not package those services into a single code set.

Understand which codes to assign for the mother and baby

Confusion about maternity codes often stems from a lack of understanding about which diagnosis and procedure codes are appropriate for obstetric/maternity services. ICD-9-CM codes 630–679 are specific to the mother and what is happening to her, and codes 760–779 are for the fetus/neonate/baby. It is important to know whether you are coding for the mother, the baby, or both, and assign the appropriate diagnosis codes.

To ensure that coders get started on the right track, they should have a clear understanding of which procedures and/or services the physician provided on a particular date of service. They should also remember to include fourth and fifth digits for appropriate diagnosis codes.

It’s also important to audit coding for these services to ensure correct physician documentation of any obstetric/maternal or fetal service to support the procedures your facility bills consistently exists in the medical record. This documentation should include very specific diagnoses and descriptive notation of what services the physician rendered. For example, when a physician performs an artificial rupture of membranes (AROM), for which you should report ICD-9-CM procedure code 73.01 (Induction of labor by AROM), the physician should document how and why he or she performed the service. If these basics are missing, you should query the physician.

When in doubt about which diagnosis or procedure code(s) to apply, refer to your ICD-9-CM Volume 3 (i.e., procedure codes) to clarify the appropriate application of the official ICD-9 guidelines and conventions of coding. In chapter 13 (Obstetrical procedures) of your ICD-9-CM Manual Volume 3, code sets 72–75 cover the majority of the procedure codes you will need to bill obstetric/maternity services. Note the following code categories:

• 72 (Forceps, vacuum, and breech delivery)

• 73 (Other procedures inducing or assisting delivery)

• 74 (Cesarean section and removal of fetus)

• 75 (Other obstetric operations)

In addition to the obstetrical code sets, coders also need to be familiar with code sets 65–71 from chapter 12 (Operations on the female genital organs). It is uncommon, but there are occasions when physicians provide services that fall within chapter 12 codes to obstetric/maternity patients. Note the following code categories:

• 65 (Operations on ovary)

• 66 (Operations on fallopian tubes)

• 67 (Operations on cervix)

• 68 (Other incision and excision of uterus)

• 69 (Other operations on uterus and supporting structures)

• 70 (Operations cul-de-sac)

• 71 (Operations on vulva and perineum)

Correct coding hinges upon details in documentation

Clear physician documentation and a good understanding by coders of what takes place during the maternity stay are vital for accurate coding and billing of obstetric/maternity-related services. Although these are not all-inclusive lists, the services below are normally included in obstetric care.

Antepartum services may include:

• Ultrasound(s) and radiologic services related to obstetrics

• Cerclage

• Insertion of a cervical dilator

• Echocardiography

• External cephalic version

• Fetal biophysical profile

• Administration of Rh immune globulin

• Amniocentesis

• Fetal non-stress test (NST)

• Blood typing and Rh factors and lab/pathology services related to maternity care

• Management and/or observation care of a chronic, stable illness (e.g., pre-eclampsia, premature labor, diabetes, epilepsy, lupus erythematosus or hypertension, premature rupture of membranes)

Delivery services may include:

• Admission to the hospital

• Supervision and/or management of active labor, including induction services

• Normal labout or cesarean delivery

• Delivery of placenta

• Episiotomy

• Fetal services and monitoring (e.g., fetal EKG)

• Repair of uterus, cervix, during delivery

Postpartum care may include:

• Procedures for post-delivery complications (e.g., hematoma, obstetric hemorrhage status post delivery, retained placenta)

• Services for sterilization

• Symptoms and complications related to the pregnancy post-delivery (e.g., seizures, diabetes, asthma)

Bear in mind common diagnoses and symptoms

Coders need to understand the diagnoses applicable for procedures performed for maternity care patients. Coders should be on the look-out for certain diagnoses and symptoms that may indicate that a particular patient falls into a “risk” diagnosis area. These diagnoses often include the comorbidity/complication (CC) designation for the DRG grouper weights. Consider the following list of common obstetric/maternity complication diagnoses and codes:

• Pre-existing diabetes (648.0X)

• Gestational diabetes mellitus (648.8X)

• Pregnancy-induced hypertension or pre-eclampsia (642.4X)

• Fetal anomaly or abnormal presentation (i.e., 653.5X)

• Multiples (651.0X)

• Placenta previa (641.0X–641.1X)

• Hypertension (642.2X–642.3X)

• HIV or abnormal screen (648.9X)

• Prior preterm delivery (V23.41)

• Prior preterm labor requiring admission (e.g., early cervical change) (V23.49)

• Intrauterine fetal demise (656.4X, 632)

• Prior cervical or uterine surgery (V23.8X)

• Fetal anatomic abnormality (655.XX)

• Abnormal fetal growth (653.4X)

• Preterm labor requiring admission (644.0X–644.1X)

• Abnormal amniotic fluid (657.0X, 658.0X)

• Bleeding (641.8X)

• Anemia (648.2X)

• Recurrent urinary tract infections or stones (646.6X)

• Advanced maternal age (V23.82, 659.5X, 659.6X) (35 years or older at estimated date of confinement [i.e., estimated delivery or due date])

• Young maternal age (V23.83, 659.8X) (Younger than 16 years at estimated date of confinement)

• Past complicated pregnancy (V23.89, 646.8X)

In coding and sequencing diagnoses, fifth digits play an important part in telling the story on claims. ICD-9-CM codes 640–649 and 651–676 require a fifth digit, and the list below denotes the specific episode of care, providing a vital understanding of whether the patient is in the antepartum, delivery, or postpartum phase of care. The fifth digits for these codes are as follows:

• 0: Unspecified

• 1: Delivered with or without mention of antepartum condition

• 2: Delivered with mention of postpartum complication

• 3: Antepartum condition or complication

• 4: Postpartum condition or complication

It is rarely appropriate to report a 0 (Unspecified) for the fifth digit. Verify with a supervisor before using a 0 as the fifth digit. Only report an unspecified code when you do not have enough information or documentation from the provider in the record. As a coder, you should query the physician, or request additional physician documentation to assign accurate a diagnosis code for the services, rather than use an unspecified code.

When administering obstetric/maternity services, sometimes the unexpected happens. Coders need to know how to assign codes in the event of a miscarriage, ectopic tubal pregnancy, or an ectopic abdominal pregnancy. For these cases, coders need to look to the procedure codes in chapter 12 and sometimes chapter 13. For example, consider billing the following codes for the surgical intervention for the miscarriage or ectopic pregnancy:

• 66.62 (Salpingectomy with removal of tubal pregnancy)

• 69.02 (Dilation and curettage following delivery or abortion)

• 74.3 (Removal of extratubal ectopic pregnancy)

Patients with multiple gestations also present significant coding challenges. For these cases, coders need to bill for multiple procedures based on how many times the physician performs them. This number should correspond directly with the number of babies the physician delivers.

For example, you would report two vaginal deliveries for a patient who delivers twins. These procedure codes can be different if twin A is delivered vaginally with code 72.4 (Forceps rotation of fetal head) and twin B is delivered with code 72.71 (vacuum extraction with episiotomy). But if both twins are delivered in the same manner, report the same procedure code twice to denote the twin delivery.

Coding example

Consider the following operative note for a vaginal delivery.

. . . The patient progressed to delivery of head at the perineum, and was suctioned on the perineum showing a light meconium with patient pushing. The patient would intermittently stop and not push; however, there was shoulder dystocia. Forceps were used for a DeLee maneuver to rotate the fetal head, which seemed somewhat large (Code 72.4); the forceps again were used with gentle traction on the baby’s head (code 72.0). There was still some shoulder dystocia. At that point with corkscrew maneuvers, the posterior shoulder was delivered. Once the shoulder was delivered, the rest of the infant was easily delivered. The baby was bulb suctioned. The cord was then clamped, cut, and the baby was handed to the waiting pediatric team. At that time, delivered a male with 6 and 9 Apgars, weight 9 lbs 11 oz. The placenta was delivered intact with three-vessel cords. Cervix is intact, primary perineal laceration was repaired with 3-0 Vicryl for hemostasis (code 75.69). Estimated blood loss was 500 cc. The patient did well and the baby was vigorous at five-minute Apgar.

Possible diagnosis codes for the maternal chart

• 653.41 (Fetopelvic disproportion, delivered [large fetal head])

• 660.41 (Shoulder (girdle) dystocia during labor and deliver, delivered)

• 656.81 (Other specified fetal and placental problems affecting management of mother, delivered [meconium])

• 664.01(First-degree perineal laceration, with delivery)

• V27.0 (Outcome of delivery, single liveborn)

Possible diagnosis codes for the fetal chart

• 763.1 (Fetus or newborn affected by other malpresentation, malposition, and disproportion during labor and delivery [i.e. shoulder dystocia])

• 763.2 (Fetus or newborn affected by forceps delivery)

• 763.84 (Other specified complications of labor and delivery affecting fetus or newborn, meconium passage during delivery)

• V30.00 (Single liveborn, born in hospital, delivered without mention of cesarean delivery)