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August 16, 2010

Coding for Multiple Gestation
For The Record
Vol. 22 No. 15 P. 28

Multiple gestations are assigned to ICD-9-CM category 651. The appropriate code assignment depends on the number of fetuses present and whether there is fetal loss with retention of one or more fetuses. If a patient presents with multiple gestation, code 650, Normal delivery, may not be assigned even if there are no other complications. The fact that the patient has more than one gestation makes it a complication. The following are the specific codes under category 651:

• 651.0, Twin pregnancy;

• 651.1, Triplet pregnancy;

• 651.2, Quadruplet pregnancy;

• 651.3, Twin pregnancy with fetal loss and retention of one fetus;

• 651.4, Triplet pregnancy with fetal loss and retention of one or more fetuses;

• 651.5, Quadruplet pregnancy with fetal loss and retention of one or more fetuses;

• 651.6, Other multiple pregnancy with fetal loss and retention of one or more fetuses;

• 651.7, Multiple gestation following (elective) fetal reduction, which includes fetal reduction of multiple fetuses reduced to single fetus;

• 651.8, Other specified multiple gestation; and

• 651.9, Unspecified multiple gestation.

A fifth digit of 0, 1, or 3 is required for the above codes to denote the episode of care. A fifth digit of 1 is for a delivery with or without mention of antepartum condition. A fifth digit of 3 denotes an antepartum condition or complication. A fifth digit of 0 is for an unspecified episode of care and should rarely be used, as the medical record will identify whether the patient delivered or not. A fifth digit of 2 or 4 (postpartum complication) is not allowed with category 651.

A patient expecting more than one fetus could develop complications during delivery, such as breech presentation, delayed delivery, or locked mates. If a patient with multiple gestations has a breech presentation or other malpresentation of at least one fetus, assign code 652.6 instead of one from category 651. If the malpresentation is causing obstructed labor, code 660.0 is sequenced first followed by code 652.6. If there is a delayed delivery between the births, assign code 662.3 first followed by the appropriate code from category 651.

ICD-9-CM does not define what amount of time must lapse between births before it is considered a delayed delivery. The coder should be guided by the physician documentation. If the documentation is unclear, ask the physician for clarification.

Multiple gestation delivery with locked mates is assigned to code 660.5 first followed by the appropriate code from category 651.

When a delivery has occurred, an outcome of delivery code (category V27) should also be assigned on the mother’s record as a secondary diagnosis. “These codes are not to be used on subsequent records or on the newborn record” (ICD-9-CM Official Guidelines for Coding and Reporting, effective October 1, 2009, p. 46). The outcome of delivery code will identify whether the mother had a single or multiple birth and whether the outcome was liveborn or stillborn. For multiple gestations, one code from the following list will be selected:

• V27.2, Twins, both liveborn;

• V27.3, Twins, one liveborn and one stillborn;

• V27.4, Twins, both stillborn;

• V27.5, Other multiple birth, all liveborn;

• V27.6, Other multiple birth, some liveborn;

• V27.7, Other multiple birth, all stillborn; and

• V27.9, Unspecified outcome of delivery, which includes unspecified outcome of infants for multiple birth.

If a mother delivers a baby outside the hospital and is then admitted for routine postpartum care, a code from category V27 is not assigned since the delivery occurred prior to admission (AHA Coding Clinic for ICD-9-CM, 1995, fourth quarter, pages 29-30). However, with the birth of multiples, if one baby is born outside the hospital and another is born after hospital admission, then an outcome of delivery code is assigned and based on the outcome of all babies born. For example, V27.2 would be assigned on the mother’s record for two liveborn twins if one baby was born before admission and the other was born after admission (AHA Coding Clinic for ICD-9-CM, 1992, third quarter, p. 10).

Coding and sequencing for multiple gestation 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 Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.