Health Information Management

Review guidelines for coding pregnancy, its complications

JustCoding News: Inpatient, May 23, 2012

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Depending on the demographics of the region a hospital serves, its coders could determine code assignment for hundreds of deliveries and pregnancy-related services annually. Therefore, reviewing the related coding guidelines is helpful.

Principal diagnosis
Coders must remember that pregnancy is a disease process separate from other disease processes that patients may experience, says Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA, COBGC. Even when patients present for other conditions (e.g., hypertension management), pregnancy is the principal diagnosis, says Webb, a coder at St. Alphonsus Regional Medical Center in Boise, Idaho, and an AHIMA-certified ICD-10-CM/PCS trainer.

A pregnancy diagnosis is always reported first, she says. This may seem counterintuitive to coders trained to report the principal diagnosis as the condition after study that is chiefly responsible for admission, she says.

Webb recently coded a case in which a pregnant patient was admitted for treatment of a broken leg. The principal diagnosis was pregnancy because it affected decisions regarding treatment of the leg (e.g., administration of certain drugs or sedation), she says.

Sequencing an actual delivery is somewhat different. The ICD-9-CM Official Guidelines for Coding and Reporting, §I.C.11.b.4 (p. 45/107) state: "When a delivery occurs, the principal diagnosis should correspond to the main circumstances or complication of the delivery."

This guideline further explains that for cesarean deliveries, coders should select the principal diagnosis based on the condition established after study that was responsible for admission. This means that if a patient is admitted with a condition that results in a cesarean delivery, coders should report the condition that prompts the delivery as the principal diagnosis. If the admission is unrelated to the condition that results in a cesarean delivery, coders should report the condition that relates to the admission as the principal diagnosis.

Current guidelines indicate that ICD-9-CM code 648.21 is the principal diagnosis for a woman with a pregnancy complicated by anemia who undergoes a cesarean delivery due to fetal distress not present at admission, says Susan Proctor, RHIT, CCS, CPC, a coding consultant in Willits, Calif., and an AHIMA-certified ICD-10-CM/PCS trainer.

Other complications
Coders must also capture all other conditions that ¬affect management of a pregnancy, says Proctor.
The ICD-9-CM Official Guidelines for Coding and Reporting, §I.C.11.a.1 (p. 44/107) state: "It is the provider's responsibility to state that the condition being treated is not affecting the pregnancy."

Report all documented conditions unless physicians indicate otherwise, says Proctor. "All conditions are complications unless stated otherwise by the provider, and the Chapter 11 codes are sequenced first," she says.

Signs and symptoms
Signs and symptoms may also pose coding challenges. This is because physicians often document signs and symptoms that may indicate a more definitive condition, says Webb. Dehydration and excessive vomiting—commonly experienced and documented during pregnancy—could indicate metabolic syndrome. Elevated blood pressure, severe headaches, and edema could indicate preeclampsia. Query when documentation is vague; the physician may point to a more definitive diagnosis, she says.

Failure to progress
Physicians continue to document nonspecific terminology despite more specific codes and diagnoses available in ICD-9-CM, says Proctor. Failure to progress (i.e., inability to deliver without a cesarean) is one example, she says. Coding Clinic, July-August 1985, p. 11, instructs coders to report code 661.21 (uterine inertia, delivered) when physicians document failure to progress.

Decreased fetal movement
Decreased fetal movement (655.7x)—a condition in which a mother cannot feel the fetus move—can be an early sign of a problematic pregnancy. ¬Physicians often document this term before administration and interpretation of a fetal non-stress test that indicates normal development, says Webb.

The following documentation is necessary to help ¬determine whether decreased fetal movement is present:

  • Was the fetus stressed during the fetal non-stress test?
  • How many heartbeats per minute, including accelerations and decelerations, did the fetus have during the test? Is this normal?
  • How many contractions occurred during the test?
  • What was the patient's blood pressure during the test?
  • Was the patient hydrated or dehydrated during the test?

Query when documentation is unclear, says Webb.

Fetal conditions and management of mothers
Coders should assign codes from the following categories only when the fetal condition is responsible for modifying management of a mother:

  • 655, known or suspected fetal abnormality affecting management of the mother
  • 656, other known or suspected fetal and placental problems affecting management of the mother

For example, report fetal conditions that require termination of a pregnancy, diagnostic ¬studies, additional observation, or special care. The mere existence of a fetal condition does not justify assigning a code for that condition, according to the guidelines.

Complicating matters is that one physician could be treating the mother and another could be monitoring the fetus, says Webb. Interconnected electronic medical records help ensure documentation is updated and available. This isn't always possible, making it difficult for coders to determine whether certain fetal conditions affect the mother, she explains.

Normal deliveries
Normal deliveries (code 650) are so rare that Proctor asks colleagues to review cases to ensure she didn't forget to code something the physician documented. Coders should remember that in addition to procedures listed under the description for code 650, normal deliveries include induction of labor by artificial rupture of membranes without any indication. Refer to Coding Clinic, Third Quarter 2000, p. 5, for more information.

The term abortion has a legal connotation, but several more specific terms are also associated with this diagnosis, says Webb. These include the following:

  • Spontaneous abortion, including miscarriage (634.x)
  • Legally induced abortion (635.x)
  • Illegally induced abortion (636.x)
  • Unspecified abortion, including retained products of conception following abortion, not classified elsewhere (637.x)
  • Failed attempted abortion (638.x)

Intrapartum care
Coders often forget to report codes for ¬complications that occur during labor and delivery (codes 660-669), says Webb. For example, when a delivery trauma, such as an episiotomy (73.6), occurs, ¬coders often forget to report a code for cervical laceration (655.3x).

ICD-10 pregnancy, childbirth, and puerperium codes are more detailed than their ICD-9-CM counterparts and often refer to the fetus as a product of conception, says Proctor. Furthermore, ICD-10-PCS fetal and obstetrical MRI codes will require coders to capture the specific fetal body part examined and whether contrast was used, says Webb.

Editor’s note: This article was originally published in the May issue of Briefings on Coding Compliance Strategies. Email your questions to Senior Managing Editor Andrea Kraynak, CPC, at

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