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Question:
My question concerns a scenario I came across in one of the coding books I’m practicing with. The case involved a delivery and had codes ending with fifth digits of 1 and 2 (antepartum and postpartum conditions, delivered). The answer in the book for this particular case had the following diagnoses listed: 667.02, 648.21, 285.1, 646.62, 670.02, 647.61, 054.9, 646.11, 664.31, 663.31, and V27.0.

I was taught to list codes ending with fifth digit 1 before any ending with fifth digit 2. Would you say that the book’s answer is incorrect? First, let me explain that I’m not confused about when to use fifth digit 1 or 2 for the different diagnoses in this case. My confusion lies with whether or not a code ending with the fifth digit of 2 can be used as the principal diagnosis when there are accompanying diagnoses ending with 1. One explanation I’ve been given concerning a code ending with 2 could be used as the principal diagnosis would be if the patient had a perfectly normal delivery with no antepartum complications but had a postpartum complication during the hospital stay for the delivery. In this situation, there would just be the code ending with 2 and the V27 code along with any procedures. Unfortunately, this example does not describe the scenario I’ve written about.

I just realized that I keep referring to 667.02 as the principal diagnosis, which would imply that this case is an inpatient coding case. However, this case was set up in the book as a practice case for physician coding, not facility coding. Maybe that’s why 667.02 could be listed as the first diagnosis? I just know that, based on what I was taught as far as facility inpatient coding, I would not be using a code ending with 2 as the principal diagnosis. So I guess it boils down to the following two questions: 1. If this scenario were set up as an inpatient case, would my understanding about how to code it be correct, and 2. If the coding order I stated in question No. 1 is correct, would it also apply to physician coding and make the answer of 667.02 incorrect?

P. V.
Dayton, Ohio

Response:
In the case you describe, it is safe to say it depends on the situation. There are several guidelines pertaining to coding obstretric cases and the appropriate use of fifth digits. To assist with clarification, I would refer you to the Official Guidelines for Coding and Reporting (Chapter 11L Complications of Pregnancy, Childbirth and Puerperium). There are several rules about the use of fifth digits, so you need a scenario to help clarify the use.

One example, section i 4 describes the use of fifth digits during the same admission as delivery. Bottom line, what is the rule that is governing your coding decision on a specific case? With some diagnoses, it doesn’t make sense to use the fifth digit of 2 and in some situations, it doesn’t make sense to use fifth digit of 1.

Let’s see if we can make sense of the pregnancy codes. There is no sequencing rule about using the fifth digit of 1 over 2. But let’s do frame the decision about sequencing back to the definition of principal diagnosis to get your answer. According to official coding guidelines, “When a delivery occurs, the principal diagnosis should correspond to the main circumstances or complication of the delivery.“

In this case, the principal diagnosis is based on the complication of delivery (retained placenta). The anemia of the mother (648.21) did not correspond to the complication of delivery; therefore, it does not meet the definition of principal diagnosis for this obstetrics case.

I hope this helps. Sometimes when we learn rules based on absolutes (choosing a fifth digit of 1 over 2) doesn’t help to explain why we do what we do.

— Gail Smith, MA, RHIA, CCS-P, is director of the HIM program at the University of Cincinnati.