Health Information Management

Learn about the Bishop's Score and its relationship to labor and delivery

JustCoding News: Outpatient, May 2, 2012

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by Lori-Lynne Webb, CPC, CCS-P, CCP

Coders are faced with many different procedures, tests, and abbreviations every day. The Bishop’s Score is one of those. The Bishop’s Score is primarily a scoring system to assess:

  • The viability and/or success of an induction of labor
  • The odds of a spontaneous pre-term delivery
  • Whether a cesarean section should be considered instead of a vaginal delivery

As a coder, this terminology may come up within the antepartum care of the patient. Coders may consider the Bishop’s Score when the antepartum care is above and beyond the global package, or as a component of a separately identifiable evaluation and management (E&M) visit during the antepartum care.

Background on the Bishop’s Score

In the 1960s, Edward Bishop, MD, developed a five-component point based scoring system to determine the possibility of an uncomplicated pregnancy at term with a successful vaginal delivery. This was revolutionary, considering in the 1960s, providers rarely had access to or used ultrasound or accessible for their pregnant patients.

The Bishop’s Score does not relate to the length of the labor, or the ease or difficulty of the labor and delivery of the baby. It only relates to the potential success or failure of a vaginal delivery outcome.

Determining the Bishop’s Score

The physician assess the Bishop’s Score from a vaginal examination when the patient is between 38 and 41 weeks (i.e., at term). Pregnancy due dates or estimated delivery dates (EDD) can vary. Providers usually calculate due dates from the first day of a women’s last menstrual period (LMP).

The physician can also estimate due date using a transvaginal or transabdominal ultrasound. Most providers state that an EDD can have an error rate of +/- of 2 weeks. An estimated fetal weight (EFW) can also be noted as +/- one to two pounds.

Once a provider has decided to perform a Bishop’s Score, the scoring itself is comprised of five separate components directly related to the cervix. The provider assigns a score of 0-2 or 0-3 for each component, with the highest possible score being 13. The higher the Bishop’s Score, the more likely the patient will have a successful vaginal delivery. The lower the Bishop’s Score, the more likely a woman will need to have a labor induction, or the possibility of a cesarean section delivery. The five components of the Bishop’s Score are:

  1. Cervical dilation: The measure of the diameter of the stretched cervix, i.e., closed, 2 cm, 7 cm, 10 cm.
  2. Cervical effacement: The measure of the stretch already present in the cervix. When a cervix is stretched, it becomes thinner, similar to the stretching of rubber band or balloon.
  3. Fetal station: This component describes the position in of the fetus' head in relation to the distance from the ischial spine (approximately 8–10 cm) as a bony protrusion. Negative numbers indicate that the head is further from the cervix.
  4. Cervical position: The component measures the anatomical location of the cervix in relation to the vagina. A patient with an anterior cervical position, meaning the cervix is better aligned with the uterus, could have an increased likelihood of spontaneous delivery. When the patient’s cervix is positioned posteriorly, she has a lower likelihood of impending labor.
  5. Cervical consistency: The component denotes the overall firmness of the cervix. A firm cervix can be noted in women who have never delivered, or have had previous cervical procedures performed. In women who have had multiple pregnancies, the cervix is overall much softer.

Meaning of the Bishop’s Score
The Bishop Score system is generally as follows:
 

Score Cervix Dilatation Cervix
Effacement
Fetal Station Cervix
Position
Cervix Consistency
 0  closed  – 30%  -3 Posterior Firm
1 1–2 cm 4 –50% -2 Mid-position Moderately Firm
 
2 3–4 cm 60–70% -1 Anterior Soft
3 5+ cm 80+% +1    

If the Bishop’s Score is less than 5, the patient is unlikely to start labor without an induction (i.e. chemical, cervical ripening assistance, or cesarean consideration). If the Bishop’s Score is 8 or higher, the patient is more likely to begin labor spontaneously.

Some providers who perform a Bishop’s Score may also add an additional point to the score if the patient has pre-eclampsia. Providers may also add an addition point for each previous vaginal delivery.

On the other hand, providers may subtract a point if the patient is past her due date (greater than 40 weeks), has no previous vaginal deliveries, or suffered a pre-term premature rupture of membranes.

Coders need to thoroughly understand the terminology, and what is involved with the Bishops Score. Coders also need to consider the clinical documentation of the Bishop’s Score and its relationship to the medical decision making process of E&M if a coder elects to code and bill for a separately identifiable E&M service outside of the global maternity package.

The provider may note the actual Bishop’s Score documentation within the examination of the patient or as a separate examination/testing notation within the body of the record.

Coders should note that the physical examination of the cervix falls under the examination portion of the E&M audit criteria. Coders should also keep in mind that the provider calculated the Bishop’s score itself as part of the medical decision-making portion of the E&M.

The medical provider must document the cervical exam and its findings, then also note whether those findings were integral to the medical decision making processes. If all that criteria is documented and met, then the coder can determine if a separately identifiable E&M visit should be coded and/or billed.

Documenting a Bishop’s Score

Below is a mini-documentation of a Bishops Score, and how it may appear in an antepartum visit record.

Patient is a 26-year-old gravida 3, para 2, female who has had 1 vaginal delivery followed by a cesarean section for fetal distress and triple nuchal cord. She is now presently 40 weeks and 1 day gestation and was scheduled for elective induction today in the labor and delivery unit. However, upon presentation, patient states no current contractions. I note good fetal movement. Exam shows cervical dilation at 2cm, 50% effaced at a (-2) station. Cervix is in the anterior position but firm. Bishop score results = 5.

At this time, we will cancel today’s induction, and reschedule induction for 5 days from now when patient will be at 40-6/7 weeks’ gestation. Patient is informed to proceed to labor and delivery if she goes into labor between now and then. Patient is amenable to this. All her paperwork and consents for a vaginal birth after cesarean have been signed and are in the chart


Editor’s note: Lori-Lynne Webb, CPC, CCS-P, CCP, is an independent consultant in Melba, Idaho. Email her at LORIWEBB@sarmc.org or webbservices.lori@gmail.com.
 



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