Procedure Practice 10/15/00 - Coding Recommendations

Feature Article 10/15/00:

ICD-9-CM Chapter 11:
Complications of
Pregnancy, Childbirth, and the Puerperium

Chapter 11 Overview - Common Terms - Coding Guidelines
  

Chapter 11 contains codes for normal pregnancy and delivery, miscarriage, abortion, and various obstetrical complications. If you don't regularly code obstetrical cases, you may find this chapter a challenge. This month, we offer a review of pertinent coding guidelines along with coding scenarios to improve your coding expertise in this area.
 

Chapter 11 Overview

Chapter 11 is divided into the following diagnosis code categories:

Common Terms

Following are some of the more common terms used in obstetrics and their definitions.

Abortion

termination of pregnancy before the 22nd week of pregnancy; or the expulsion or extraction of all or part of the placenta with or without an identifiable fetus weighing less than 500 grams

 

Abruptio placenta

premature detachment of the placenta, often accompanied by maternal hemorrhage and shock
  

Chorion

the outermost extraembryonic membrane that ultimately evolves into the placenta
 

CPD (cephalopelvic disproportion)

the condition in which the head of the fetus is too large for the pelvis of the mother
 

Delivery

expulsion or extraction of an infant, the placenta, and membranes
 

Decidua

the endometrium of the pregnant uterus that is shed at delivery
 

Eclampsia

severe toxemia of late pregnancy characterized by hypertension, edema, and proteinuria accompanied by seizure or coma
 

Ectopic pregnancy

implantation of a fertilized ovum outside the uterus; the most common site is a fallopian tube, but ectopic pregnancies may implant in other locations such as the cervix, ovary, or abdominal cavity
 

Elderly primigravida

first pregnancy in a woman who will be 35 years or older at the time of delivery
 

G, P

abbreviated form of the words "gravida" (pregnant) and "para" (delivered), often used by obstetricians to express the number of a patient's pregnancies and deliveries; for example, a woman who has been pregnant twice and has delivered 2 infants would be a "G2P2" patient
 

Hydatidiform mole

an abnormal pregnancy resulting from a pathologic ovum that results in a cystic structure resembling a cluster of grapes
 

Hyperemesis gravidarum

pernicious vomiting during pregnancy
 

Molar pregnancy

abnormal pregnancy in which the ovum degenerates into a fleshy tumorous mass within the uterus
 

Oligohydramnios

an abnormally low volume of amniotic fluid, generally less than 300 ml of amniotic fluid at term
 

Placenta accreta

an abnormally adherent placenta that may require manual extraction following delivery
 

Placenta previa

low implantation of the placenta within the uterus so that the placenta completely or partially obscures the inner cervical os; painless hemorrhage in the third trimester of pregnancy is the most common symptom
 

Polyhydramnios

an excessive amount of amniotic fluid
 

Pre-eclampsia

a condition of late pregnancy characterized by hypertension, edema, and proteinuria
 

Puerperium

the postpartum period of 42 days (6 weeks) following delivery
 

Retained products of conception

incomplete expulsion of the fetus, placenta, amniotic sac, chorion or decidua following abortion or delivery, requiring evacuation of remaining tissues
 

Vasa previa

presentation of the umbilical cord at the point of insertion into the placenta in front of the fetal head during labor. Also known as velamentous umbilical cord insertion
 

VBAC

abbreviation for vaginal birth after Cesarean section, used to indicate successful vaginal delivery in a patient whose previous pregnancy was delivered via Cesarean section

 

Coding Guidelines

The following guidelines were developed and approved by the Cooperating Parties, the Coding Clinic Editorial Advisory Board, and the American College of Obstetricians and Gynecologists.
 

General Rules

• All obstetric cases require a code from Chapter 11.
   
• Pregnancy that is incidental to an encounter is coded V22.2, Pregnant state, incidental. It is the physician's responsibility to document that the condition being treated is not related to the patient's pregnancy.
   
• Codes in Chapter 11 have sequencing priority over codes from other ICD-9-CM chapters. However, additional codes may be used to further specify a condition.
   
• Chapter 11 codes are used only on the maternal record, never on the newborn record.
   
• Outcome of Delivery codes from series V27.0 through V27.9 must appear on the maternal record whenever delivery occurs. These codes are not used on any subsequent maternal records, nor are they used on the newborn record.
   

Selection of Principal Diagnosis

• The circumstances of the encounter govern the selection of the principal diagnosis.
   
• If delivery did not occur, the principal diagnosis must correspond to the principal complication of the pregnancy that necessitated treatment. If multiple complications were treated, any of the complications may be sequenced first.
   
• If delivery occurred the principal diagnosis must correspond to the main circumstances or complication of delivery. In cases of Cesarean deliveries, the principal diagnosis should correspond to the reason for the performance of the Cesarean section, unless the patient was admitted for a condition unrelated to the Cesarean delivery, for example, a patient admitted following trauma who subsequently required Cesarean delivery during the same admission.
   
• Routine prenatal visits without complications are coded V22.0, Supervision of normal first pregnancy, or V22.1, Supervision of other normal pregnancy. Do not use these codes in conjunction with codes from Chapter 11.
   
• Prenatal visits for patients with high-risk pregnancies are assigned a code from category V23, Supervision of high-risk pregnancy. Secondary codes from Chapter 11 may be used to specify the nature of the high-risk condition if appropriate. A thorough review of any pertinent exclusion notes is essential to be certain that the V codes are correctly used.
   

Chapter 11 Fifth Digits

• Categories 634-637 are used to code various types of abortion: spontaneous abortion (634), legally induced abortion (635), illegally induced abortion (636), and unspecified abortion (637). All codes in these ranges require a 5th digit from the list below to further specify the abortion:

0 - Unspecified
1 - Incomplete
2 - Complete

• Categories 640-648 and 651-676 require 5th digits to indicate whether the encounter is antepartum or postpartum and whether delivery occurred. The 5th digit subclassifications are:

0 - Unspecified as to episode of care or not applicable
1 - Delivered, with or without mention of antepartum condition
2 - Delivered, with mention of postpartum complication
3 - Antepartum condition or complication
4 - Postpartum condition or complication

• Only 5th digits 1 and 2 may be used (as appropriate) for multiple coding of a single episode of care, since both indicate delivery during the current episode.
   
• The 5th digits 0, 3, and 4 may never be used in combination with any other 5th digits during the same episode of care.
   
• Pay attention to the 5th digit choices noted for each code within these ranges; not all 5th digits are appropriate for every code.
   

Guidelines for Specific Diagnoses and Code Ranges

Ectopic and Molar Pregnancies

Categories 630-633 identify abnormal pregnancies:

• Assign 630 for hydatidiform moles.
   
• Category 631 identifies other abnormal products of conception, e.g., blighted ovum.
   
• Missed abortions are coded to category 632. Use this code to identify cases of early fetal death before completion of 22 weeks' gestation with retention of the fetus or retained products of conception.
   
• Ectopic pregnancy is coded to category 633 with the appropriate 4th digit to indicate the site of the ectopic pregnancy.
   

Abortions

• The 4th digit subdivisions 1 through 9 for categories 634-638 identify specific complications of abortions.
   
• Use the appropriate 5th digit for categories 634-637.
   
  • The 5th digit 1 indicates that not all products of conception were expelled from the uterus prior to the episode of care.
     
  • The 5th digit 2 indicates that all products of conception were expelled prior to treatment.
     
  • The 5th digit 0 is used when this information is unspecified or unknown.
     
• Codes from categories 640-648 and 651-657 with a 5th digit of 3 may be used as secondary codes to identify the complication leading to the abortion.
   
• Codes from categories 660-669 may not be used with abortion codes.
   
• Codes from category 639 are used for all complications following abortion. Do not assign a code from this range with codes from categories 634-638.
   
• A code from category 639 may be used with a code from 630-633 to identify complications that occur during the episode of care for an ectopic or molar pregnancy.
   
• Subsequent admissions for retained products of conception following abortion are assigned the appropriate code from category 634, Spontaneous abortion, or 635, Legally induced abortion, with a 5th digit of 1 (incomplete).

  NOTE: This advice is appropriate even if the patient was previously discharged with a diagnosis of complete abortion.

• If an attempted pregnancy termination resulted in a liveborn fetus assign 644.21, Early onset of delivery, with an appropriate code from category V27, Outcome of delivery. Also assign the correct procedure code for the attempted termination.
   

Hemorrhage in Pregnancy

• Assign a code from category 640 for hemorrhage that occurs before 22 weeks' gestation.
   
• The range of codes from 641.00-641.23 identifies antepartum hemorrhage due to placental abnormalities.
   
• 641.3 with the appropriate 5th digit denotes antepartum hemorrhage associated with coagulation defects.
   
• Antepartum or intrapartum hemorrhage due to trauma, uterine fibroids, or other specified cause is coded to 641.8 with the appropriate 5th digit.
   
• Assign 641.9 with the appropriate 5th digit for unspecified antepartum or intrapartum hemorrhage.
   
• Hemorrhage due to vasa previa is coded 663.5 with the appropriate 5th digit.
   
• Postpartum hemorrhage is coded to category 666 with the appropriate 5th digit.
   

Normal Delivery

• Assign 650, Normal delivery, for full-term normal vaginal deliveries of single, healthy infants without any antepartum, intrapartum, or postpartum complications at the time of delivery. Additional codes from other chapters may be used with 650 to describe conditions in the mother that are not related to or complicating the pregnancy.
   
• Assign 650 if the patient had an antepartum complication that resolved prior to the admission for delivery.
   
• If used, 650 is always the principal diagnosis. It may not be used if any other code from chapter 11 is required to describe a current obstetrical complication.
   
• 650 may be used if episiotomies were performed, membranes were artificially ruptured, or if the placenta was manually extracted following delivery. For forceps, breech extraction, or Cesarean deliveries, see category 669.
   
• V27.0, Single liveborn, is the only outcome of delivery code that may be used in conjunction with 650.
   

Obstetrical Lacerations and Trauma

• Categories 664, Trauma to perineum and vulva during delivery, and 665, Other obstetrical trauma, are used to identify injuries to the mother sustained during delivery.
   
• All codes in these ranges need a 5th digit. However, be sure to select from the appropriate 5th digit choices for each code. Again, not all 5th digits are appropriate for all codes. Some common types of lacerations and traumas are described below:
   
  • First-degree perineal lacerations involve damage to only vaginal mucosa, perineal skin, or both with minimal bleeding.
     
  • Second-degree perineal lacerations involve tears of the vaginal mucosa, perineal mucosa, or both with disruption of the superficial fascia and the transverse perineal muscle.
     
  • Third-degree lacerations involve the structures mentioned above plus the anal sphincter with moderate bleeding.
     
  • Fourth-degree lacerations include those structures mentioned in the third-degree category plus entry into the rectal lumen with profuse bleeding.
     
  • Hematomas of the vulva and perineum are caused by injury to blood vessels during delivery. The injuries may be caused by normal spontaneous delivery, forceps or other mechanical extraction of the newborn, or inadequate repair of a laceration or incision.
     
  • Pelvic hematomas are caused by laceration of paravaginal blood vessels. The hematoma may form next to an ischial spine and may expand distally to the rectum.
     

Post Dated Pregnancy

• With the October 1, 2000, ICD-9-CM update, six codes were created to differentiate between post-term pregnancy (over 40 weeks, but not more than 42 weeks’ gestation), and prolonged pregnancy (over 42 weeks’ gestation). If a physician documented "post dates pregnancy," review the record carefully to determine the number of weeks of gestation in order to select the correct code from one of the following:
   

  645.10	Post-term pregnancy, unspecified as to episode of care or not applicable
  645.11	Post-term pregnancy, with or without mention of antepartum condition
  645.13	Post-term pregnancy, antepartum condition or complication
  645.20	Prolonged pregnancy, unspecified as to episode of care or not applicable
  645.21	Prolonged pregnancy, with or without mention of antepartum condition
  645.23	Prolonged pregnancy, antepartum condition or complication

• Note that only the 5th digits 0, 1, and 3 are appropriate for use with these codes.
   

Fetal Conditions Affecting the Management of the Mother

• Codes from categories 655, Known or suspected fetal abnormality affecting management of mother, and 656, Other fetal and placental problems affecting management of mother, are assigned only if the fetal condition was responsible for modifying the care of the mother, i.e., by requiring diagnostic studies, additional observation, special care, or pregnancy termination.
   
• Do not assign a code from these categories simply because a fetal condition exists. Review documentation carefully and resolve any questions with the attending physician.
   

Pregnancy with Hypertension

Hypertension complicating pregnancy, childbirth, and the puerperium is assigned to category 642. The 4th digit subcategories 0-9 identify the type of hypertension. The 5th digit subclassification (indicated below with an "x") denotes the episode of care or stage of pregnancy during which the complication occurred.

• Use code 642.0x to identify a pregnant patient whose pregnancy, delivery, or postpartum period is complicated by preexisting benign, essential, or chronic hypertension.
   
• Code 642.1x identifies hypertension secondary to renal disease that is complicating obstetrical care during pregnancy, delivery, or the postpartum period.
   
• Assign code 642.2x if pregnancy was complicated by a preexisting malignant hypertension, hypertensive heart disease, hypertensive renal disease, or hypertensive heart and renal disease.
   
• Assign code 642.3x to identify transient or gestational hypertension.
   
• Code 642.4x is used to identify pregnancy complicated by mild preeclampsia. Review the medical record for documentation of mild proteinuria, mild edema, or both.
   
• Use code 642.5x to identify HELLP syndrome, severe toxemia, or severe preeclampsia. The medical record should document severe proteinuria and/or severe edema.
   
• Assign code 642.6x for toxemia with seizures.
   
• Pregnant patients with preexisting hypertension (conditions classifiable to 642.0-642.2) may, in addition, develop superimposed preeclampsia (conditions classifiable to 642.4-642.6). Use code 642.7x to identify this combination of diagnoses.
   
• Assign code 642.9x if unspecified hypertension is noted as a complication of pregnancy, but no other signs or symptoms of preeclampsia are documented.
   

The Postpartum Period

• A postpartum complication is any complication that occurs within the 6 weeks immediately following delivery.
   
• Chapter 11 codes may also be used to describe pregnancy-related complications after the 6-week postpartum period if the physician documents that the condition is related to the previous pregnancy.
   
• Postpartum complications that occur during the delivery admission are identified with a 5th digit of 2. Subsequent admissions for postpartum complications are identified with the 5th digit 4.
   
• If the mother delivered outside the hospital and was then admitted for postpartum care without complications, assign V24.0, Postpartum care and examination immediately after delivery, as the principal diagnosis.
   

Late Effect of Complication of Pregnancy, Childbirth, and the Puerperium

• Assign 677, Late effect of complication of pregnancy, childbirth, and the puerperium for cases in which an initial complication of pregnancy developed sequelae requiring additional care or treatment at a future date.
   
• Code 677 is appropriate at any time after the initial 42-day postpartum period.
   
• Like other late effect codes, code 677 is sequenced following the code that describes the nature of the late effect. Codes from other ICD-9-CM chapters may be used to identify the late effect.
   

Other Helpful Coding Odds and Ends

• Assign V72.85, Other specified examination, for outpatient obstetrical non-stress tests. Also select the appropriate code from category V22, Normal pregnancy, or V23, Supervision of high-risk pregnancy, as a secondary diagnosis.
   
• Hyperemesis gravidarum may occur at any time during pregnancy, but most often it is a condition of early pregnancy (less than 22 weeks' gestation). Select a code from category 643 to identify this obstetrical complication. Read the code descriptions carefully to select the appropriate 4th digit subheading, and remember to assign the appropriate 5th digit.
   
• False labor is coded to 644.1 with the appropriate 5th digit of 0 or 3.
   
• Category 648 identifies other conditions that are coded elsewhere as complications of a current pregnancy, delivery, or postpartum period. Examples of conditions coded to this category include diabetes, thyroid disorders, anemia, drug dependence, mental disorders, and cardiovascular diseases. If a code from this category is used, also assign a code to identify the specific condition.
   
• Assign only 648.8 with the appropriate 5th digit to report gestational diabetes. Do not code the symptom 790.2.
   
• Multiple gestations are coded to category 651.
   
• Premature rupture of amniotic membranes less than 24 hours prior to the onset of labor is coded 658.1 with a 5th digit of 0, 1, or 3 as appropriate.
   
• Prolonged rupture of membranes 24 hours or more prior to the onset of labor is coded 658.2 with a 5th digit of 0, 1, or 3.
   
• Current pregnancy with history of a prior Cesarean section is coded 654.2 with a 5th digit of 0, 1, or 3.
   
• Obstructed labor is coded to category 660. Always sequence the obstructed labor first followed by the cause of the obstruction: fetal malposition (category 652); cephalopelvic disproportion (category 653), or abnormality of maternal organs and soft tissues of the pelvis (category 654).

Practice Makes Perfect!

Are you ready for some hands-on practice? Assign the correct ICD-9-CM diagnosis codes for the coding scenarios on our Procedure Practice page and compare your answers with our coding recommendations. Good luck!

Back to:
Top - Chapter 11 Overview - Common Terms - Coding Guidelines
  

If you have comments or suggestions about our code selections or about any topic on our Coding Edge® pages, please e-mail us at codingedge@lagunamedsys.com.

Please understand, however, that we cannot answer inquiries
unless they relate directly to our published material.