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August 29, 2005

Review of Obstetric Coding Guidelines
For The Record
Vol. 17 No. 18 P. 39

Effective April 1, the ICD-9-CM Official Guidelines for Coding and Reporting were updated and published in AHA Coding Clinic for ICD-9-CM, First Quarter 2005. The guidelines update the previously published guidelines printed in AHA Coding Clinic for ICD-9-CM Fourth Quarter 2002. Because many sections were expanded and revised, all the guidelines should be reviewed and understood. This coding column will focus specifically on the obstetric coding guidelines.

Code Requirements
When a pregnant patient is admitted, codes from AHA Coding Clinic for ICD-9-CM chapter 11 (code range 630-677) are required. The pregnancy-related codes take sequencing priority over codes from all other AHA Coding Clinic for ICD-9-CM chapters. In other words, the pregnancy code will be sequenced as principal diagnosis as it is assumed that the condition necessitating admission was either affecting the pregnancy or was affected by the pregnancy. If the condition being treated does not affect the pregnancy or is not affected by the pregnancy, then the physician must specifically document this information in the medical record. Code V22.2 will be assigned in place of any chapter 11 codes if the physician documents that the pregnancy is incidental to admission. It would not be appropriate to assign code V22.2 with any pregnancy-related code.

Although the pregnancy-related code must be sequenced first, additional codes from other chapters may be assigned as secondary diagnoses to completely classify the condition. For example, a type 1 diabetic patient is admitted in her 25th week of gestation due to uncontrolled diabetes. Code 648.03 is sequenced first, followed by code 250.03. Code 648.03 only describes the patient as having diabetes complicating the pregnancy, but the addition of code 250.03 identifies the diabetes as type I uncontrolled.

Codes located in chapter 11 are only assigned on the pregnancy record and should never be assigned on the newborn record. In addition, newborn codes located in chapter 15 of AHA Coding Clinic for ICD-9-CM are never to be used on the maternal record.

Principal Diagnosis Selection
Selection of the principal diagnosis depends on the main reason or complication of the encounter. If a patient is admitted but does not deliver during the episode of care, the principal diagnosis will depend on the circumstances of admission. If there is more than one pregnancy complication—and all are treated, evaluated, or monitored—then any of the pregnancy complication codes may be sequenced first. If the patient does deliver during the episode of care, then the main circumstance should be sequenced first. If the patient undergoes a cesarean section, then the reason necessitating the cesarean section should be sequenced as the principal diagnosis. Assign code 669.71 as the principal diagnosis if a cesarean section is performed with no mention of indication documented. It would not be appropriate to assign code 650 as the principal diagnosis when a cesarean section is performed. (AHA Coding Clinic for ICD-9-CM, 2001, first quarter, pages 11-12.)

Occasionally, a pregnant patient is admitted for a complication of pregnancy. During the hospital stay, it is decided to perform a cesarean section for other reasons. In this case, the principal diagnosis will be the condition that necessitated the admission and not the reason the cesarean section was performed.

Outcome of Delivery
Assign a code from range V27.0-V27.9 as a secondary diagnosis when a delivery occurs to show the outcome of delivery. The code will only be used once on maternal records and will not be used on subsequent admissions.

In Utero Surgery
Assign a code from category 655 to identify the fetal condition when in utero surgery is performed on a fetus. Code 75.36 should be assigned as the procedure code in these cases. A code from chapter 15 (perinatal codes) should not be assigned on the mother’s record.

HIV in Pregnancy
If a pregnant patient has an HIV-related illness or AIDS, code 647.6x is assigned as the principal diagnosis followed by code 042 and the code for the HIV-related illness. If the pregnant patient is HIV positive or has asymptomatic HIV infection, assign codes 647.6x and V08 in that sequence.

Current Conditions Complicating Pregnancy
Assign a code from category 648 for patients who have a current condition affecting pregnancy. Diabetes mellitus in pregnancy is classified to code 648.0x and gestational diabetes is assigned to code 648.8x. Code V58.67 should also be assigned as a secondary diagnosis if the patient is being treated with insulin. Codes 648.0x and 648.8x should never be used together on the same record.

Normal Delivery
To assign code 650, Normal delivery, the patient must meet the following requirements:

• full-term pregnancy;

• single liveborn infant;

• no unresolved antepartum, during the delivery, or postpartum complications

• no instrument-assisted delivery except episiotomy (73.6), amniotomy (artificial rupture of the membranes) and fetal monitoring (75.34);

• cephalic presentation; and

• no fetal manipulation.

If a patient is admitted for induction of labor without any indication or reason for the induction and no complications occur during the delivery, code 650 may be assigned as the principal diagnosis. Code 73.01 may be assigned for the induction. The assignment of this procedure code would not conflict with the use of code 650 because it does not indicate a complicated pregnancy or delivery. (AHA Coding Clinic for ICD-9-CM, 2000, third quarter, page 5.)

Postpartum Period
If a patient is admitted within six weeks after delivery, assign the postpartum complication code as the principal diagnosis. A postpartum complication is any complication occurring within the six-week period following delivery. If, however, the physician specifically documents that it is not a postpartum complication, the condition will be coded as normal and you will not assign a pregnancy-related code.

If the physician documents a postpartum condition, even after the six-week time frame, the condition should be coded as postpartum. For example, a patient is admitted nine weeks postpartum with cardiomyopathy. The physician documents postpartum cardiomyopathy. Assign code 674.84 as the principal diagnosis.

Coding and sequencing are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Health Information Systems (800-367-2447), a supplier of coding and classification systems to nearly 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payors as the result of the misuse of this coding information.

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