Obstetric Coding Quality Error Trends - IP
Obstetric Coding Quality Error Trends - IP
Obstetric Coding Quality Error Trends - IP
Outline
Key Error Trends
ICD-10-CM/PCS Coding Handbook
AHA Coding Clinic Guidance
References
Key Error Trends
➢ Missed Query Opportunities (pathology, DM type/acuity, HTN type/acuity,
complications)
➢ COVID coding (requires lab results noted in the LAB section of CAC for
reporting)
Missed Query Opportunities
As with any encounter we code, it is imperative that we not only code what
has been documented; but also, to utilize our critical thinking skills in order
to recognize when there is a need for query for additional diagnoses that are
supported by the documentation in the medical record.
Question: A patient with twin pregnancy presented with Twin A in a frank breech
position too low in the vagina for a cesarean section. The decision was made for a
vaginal breech delivery. The head of Twin A was noted to be entrapped in the cervix
so a Duhrssen incision was performed to facilitate delivery. After Twin A was
delivered, Twin B experienced recurrent prolonged heart decelerations prompting
cesarean delivery of Twin B. After surgical closure of the cesarean section, the cervix
was examined and bleeding was noted from the Duhrssen incision, which was closed
with suture. What ICD-10-PCS code is assigned for a Duhrssen cervical incision and
is an additional code assigned for the repair?
Answer: The purpose of the Duhrssen incision is to widen the opening of the
incompletely dilated cervix to facilitate delivery of the trapped fetal head. Although
Division is the appropriate root operation, ICD-10-PCS table 0W8 does not provide a
body part value for Cervix. Therefore, the root operation Dilation is the closest
available option. Coding a Duhrssen incision is similar to coding an episiotomy. The
repair of the incision is integral to the procedure and not coded separately. Assign the
following ICD-10- PCS code:
0U7C7ZZ - Dilation of cervix, via natural or artificial opening, for the Duhrssen
incision
AHA Coding Clinic Guidance
AHA Coding Clinic 2nd Qtr 2014 - Medical Induction of labor with
Cervidil Tampon Insertion
Question: A pregnant patient presents to the hospital at 40 weeks gestation in active labor.
Artificial rupture of the fetal membranes (AROM) is carried out and Pitocin is given
intravenously in the peripheral vein to augment labor. The patient had a spontaneous vaginal
delivery of a live born infant without complication. Is the administration of Pitocin to augment
active labor coded separately in ICD-10- PCS? How should this case be coded?
Answer: Assign code O80, Encounter for full-term uncomplicated delivery, as the principal
diagnosis. Codes Z3A.40, 40 weeks of gestation of pregnancy, and Z37.0, Single live born,
should be assigned to describe weeks of gestation and the outcome of the delivery.
The administration of Pitocin to augment active labor is not coded separately. In this case, the
patient presented in active labor; therefore, do no assign a separate code for the
administration of Pitocin. When Pitocin is given to induce labor, it should be coded. For the
assisted delivery and artificial rupture of the membranes, assign ICD-10- PCS procedure
codes as follows:
Question: A patient arrived at the Emergency Department (ED) with vaginal bleeding at 18
to 19 weeks gestation and had a spontaneous vaginal delivery of twin A, in the ED. Upon
the initial assessment in Labor and Delivery, twin B had heart tones, but expulsed
spontaneously within the next few minutes. The placenta of twin A was removed intact
without complication. The placenta of twin B was difficult to extract manually and remained
in utero. Due to postpartum hemorrhage and retained placenta, a suction curettage was
performed with removal of the remaining placenta. What are the diagnosis and procedure
code assignments for this case?
Answer: When documentation states that the patient had a previous cesarean
section and the type of scar is not specified, assign code O34.219 - Maternal
care for unspecified type scar from previous cesarean delivery.
Coding Clinic, Fourth Quarter 2016, pages 51-52, clarified that subsequent
pregnancy and delivery management may be determined by the previous type
of cesarean incision. Patients with a previous cesarean scar are at an
increased risk for dehiscence and uterine rupture depending on the location of
the scar.
AHA Coding Clinic Guidance
AHA Coding Clinic 3rd Qtr 2018 – Delivery with Previous Cesarean Section
and Unspecified Type of Scar
Answer: Assign code O34.211 - Maternal care for low transverse scar from
previous cesarean delivery, when a previous low transverse cesarean
section is documented.
Codes in subcategory O70.2, Third degree perineal laceration during delivery, have been
further expanded to subclassify third degree lacerations as grade IIIa, IIIb or IIIc
depending on the severity of the trauma.
The benefits for documenting subclassifications within coding include the ability
to risk stratify and/or adjust for measurement as well as the ability to identify
cases for chart review and quality improvement. The following are the new ICD-
10-CM codes for 3rd degree lacerations:
Placenta previa is a condition that occurs when some portion of the placenta is covering the
internal cervical os. It may be either complete, where the internal cervical os is completely covered
by the placenta, or partial where the internal cervical os is partially covered by the placenta. Both
conditions may result in hemorrhage and require close monitoring. In many cases, cesarean
delivery is necessary. Clinically, complete placenta previa can complicate the pregnancy, cause
early delivery, and result in morbidity. Low lying placenta is a condition where the placenta
implants low in the uterus but does not cover the cervix. Although a low lying placenta can also
develop hemorrhage, the condition can be managed with conservative treatment, and is less likely
to result in early delivery. A partial placenta previa does not typically require extensive follow-up
and is more likely to resolve as the pregnancy progresses, prior to delivery.
AHA Coding Clinic Guidance
AHA Coding Clinic 4th Qtr 2020 – Maternal Care for Other Type of Scar from Previous
Cesarean Section Delivery
Unique codes have been created to identify maternal care for other type of scar from previous
cesarean delivery (O34.218) and maternal care for cesarean scar (isthmocele) defect (O34.22).
These new codes describe non-lower uterine segment scars from previous cesarean delivery.
Women who have a prior non-lower uterine segment scar, such as a mid-transverse T incision
cesarean scar, are at higher risk of uterine rupture at the site of the previous uterine scar in
subsequent pregnancies. The surgeon may elect to perform a mid T incision when additional
space is required to deliver the infant. "Mid-transverse T incision" is an inclusion term under code
O34.218.
An isthmocele is a type of cesarean scar defect or niche that develops at the site of a previous
cesarean hysterotomy and is associated with an increased risk for uterine rupture. Other
complications may include but are not limited to infertility, placenta accrete or previa, scar
dehiscence, and ectopic pregnancy.
Question: The patient presents for elective cesarean section. During the last pregnancy, she
had undergone a mid-transverse T incision cesarean delivery. What is the appropriate diagnosis
code assignment for a patient with a previous cesarean mid-transverse T incision scar?
Answer: Assign code O34.218, Maternal care for other type scar from previous cesarean
delivery.
AHA Coding Clinic Guidance
AHA Coding Clinic 3rd Qtr 2020 – Inability of Fetal Head to Descend
Answer: Query the provider for the reason for the inability of the baby's head
to descend past +2 station and assign the appropriate code for the condition,
such as arrested labor, cephalopelvic disproportion, obstructed labor, etc.
Weeks of Gestation
A normal pregnancy ranges
from 38 weeks to 42 weeks.
Gestational age is important as
it helps guide prenatal and
delivery care. Gestational age
simulates fetal growth, due date
determination, and treating
conditions that are pre-existing,
antepartum, during
childbirth/delivery, and
postpartum. Coding becomes
difficult when a patient is
admitted in two or more
overlapping gestational weeks.
When this happens, the
gestational age used for coding
and reporting an encounter is
using the gestational age on
admission.
Present on Admission
When determining the Present on Admission (POA) status we must review
the medical record thoroughly and assure we are only assigning “Yes”
when the condition was present at the time of inpatient admission.
Assigning the POA is very important and if there is ever any question as to
the correct POA assignment, we should be querying the physician for
clarification of whether the condition was present on admission or not.
The coder should always review the lab results to determine if Z20.822 –
Exposure to COVID should be reported on every encounter. This should
be done on every obstetrics encounter and any other type of inpatient
encounter.
See specific obstetrics and COVID Coding Clinic guidance on the next
slide…
AHA Coding Clinic Guidance
See Section I.C.15.s. for COVID-19 infection in pregnancy, childbirth, and the
puerperium
Parallon Specific Audit Reviews
➢ O99.02 – Anemia Complicating Childbirth
Excludes1
O90.81 – Anemia arising in the puerperium
O90.81 – Postpartum Anemia, NOS
Parallon Specific Audit Reviews
Excludes1
O99.03 – Pre-Existing Anemia Complicating the puerperium
Parallon Specific Audit Reviews
On every obstetric encounter that is coded, the coder must review the lab
results to determine if the patient underwent evaluation for possible COVID
infection. Whenever there is a lab result with negative COVID results,
Z20.822 must be reported on the Coding Summary
Excludes1
Z22.- – Carrier of Infectious Disease
Diagnosed current infectious or parasitic disease – see Alphabetic Index
Excludes2
Z86.1- – Personal History of Infectious and Parasitic Diseases
Parallon Specific Audit Reviews
Excludes1
Z34.- – Supervision of normal pregnancy
Parallon Specific Audit Reviews
This code is assigned any time the patient has evaluation or treatment
provided that is done so based on fetal heart rate and rhythm abnormalities.
Excludes1
O77.9 – Fetal Stress, NOS
O77.8 – Labor and Delivery complicated by electrocardiographic
evidence of fetal stress
O77.8 – Labor and Delivery complicated by Ultrasonic evidence of fetal
stress
AHA Coding Clinic Guidance
Coding Clinic 4th Qtr 2013 – Meconium Amniotic Fluid and Fetal
Decelerations
Includes
Gestation Hypertension, NOS
Transient Hypertension of Pregnancy
Excludes1
Z34.- – Supervision of Normal Pregnancy
Parallon Specific Audit Reviews
This code is assigned When the patient is documented with sepsis “during
labor”. We must assure that the documentation supports that patient had
the condition prior to delivery, but during the admission. This code is not be
used when a patient is documented with puerperal sepsis (postpartum
sepsis).
Excludes1
Z34.- – Supervision of Normal Pregnancy
Parallon Specific Audit Reviews
Excludes1
Z34.- – Supervision of Normal Pregnancy
Excludes2
O75.3 – Sepsis during labor
References