Monday, September 7, 2009

In Honor of "labor" day.....

PRECIPITOUS DELIVERY? What’s a coder to do?

I covered this same subject last March, but felt it was worth a repeat....

By definition a precipitous labor, or precipitous delivery is defined as a labor and delivery which results after an unusually quick amount of time(of less than 2-3 hours) that results in a birth that may or may not be attended by the physician, and may happen outside the hospital or birthing room setting. These births can happen in areas such as in the taxi, or in the elevator. A precipitous labor and delivery can even happen in the labor and delivery room of the hospital.

However, the coding for these type of deliveries bring to the forefront a multitude of questions. The CPT book does not have any codes specifically for these deliveries, and ICD9 volume 3 does not have any either. The Diagnosis for these labor/delivery situations is 661.3x. (5 digit needs applied)

If you’re an OB/GYN coder you know that precipitous labor and precipitous deliveries happen more frequently than we would like to admit. For coders that are not in OB/GYN, we hear about them, but really don’t get the chance to understand what it means. There are many different scenario’s that meet the definition of a precipitous labor or delivery. i.e. the nurse delivered the baby as the doctor was on the way to the hospital; the baby was born in the car (taxi) on the freeway; the baby was born in the elevator etc…Some statistics state that a precipitous labor is much more common in second or later births, and approximately 2% of labors and deliveries will be precipitous.

Below are possible risk factors for having a precipitous delivery.

  • Repeated pregnancies – Multi-parity
  • Large pelvis
  • Cocaine or illicit drug use/abuse
  • Prior precipitous labor
  • Well positioned, small baby
  • Strong, intense contractions
  • Too much of the medication pitocin administered early in the labor process

In addition to the possible risk factors of the precipitous delivery, Medical complications have been noted in precipitous labors and delivery. These complications can happen in just the mother, the baby, or both

  • Mother’s loss of ability to cope with labor
  • Emotional or physical stress
  • Cervical laceration
  • Vaginal laceration
  • Perineum damage
  • Uterine atony after delivery
  • Hemorrhaging
  • Fetal distress
  • Hypoxia from intense contractions
  • Cerebral damage to the baby as a result of rapid movement through the birth canal
  • Pnumothorax as a result of rapid movement through the birth canal

It’s nearly impossible to slow down a fast labor. Once labor starts, comfort measures and constant monitoring are suggested by obstetricians, but in some cases, labor may be going so quickly that even with constant monitoring complications may arise. If possible, have the patient lie on their side, or lie down with their feet and pelvis elevated, seek medical attention immediately.

CPT does not have any guidance as to how these precipitous labor and deliveries should be coded. Review the scenario below, and then review the procedural coding options….

PROCEDURE IN DETAIL: The patient is a primi-gravida 27-year-old white female who received full prenatal care (10 visits) during her pregnancy She is currently at 36 and 6/7 weeks. She has remained normotensive throughout her pregnancy, and dipsticks remained negative.

The patient arrived in active labor after a 3-hour onset of uterine contractions with a good mechanism at 0430 hours. She was 80% effaced with a cervix dilated to 4 cm. The fetus was noted to be in a vertex presentation at a -2 station. She progressed rapidly in labor. Within 45 minutes of admission, the mother had a precipitous delivery while using the toilet. Nursing staff was in attendance in the patients room and began the protocol for care of an infant of a precipitous delivery. I arrived in the patient’s room within 3 minutes of being paged inside the hospital. I was able to deliver the placenta without complication. Uterine massage was then performed.

Upon inspection of the perineum and vagina, no rips or tears were found. Less than 200 cc of blood loss noted.

The infant did well initially postpartum with the exception of cold stress, which is normal for a premature infant. The infant cried spontaneously and vigorously. The mouth and nose were suctioned. The cord was clamped and cut. Cord blood was obtained from a 3-vessel cord. . The patient had delivered a viable male infant weighing 4 pounds 9 ounces with Apgars of 8 at one minute and 10 at five minutes.. The infant was sent to the acute care newborn nursery, and the mother will be closely observed prior to returning to her room for recovery.

Coding Option #1

59400 Vaginal Delivery (Complete package) Diagnosis 661.3X

Coding Option #2

59400.52 Vaginal Delivery w/52 mod (reduced services OB package) Diagnosis 661.3X

Coding Option #3

59426 Antepartum care only 7 or more visits or 59425 Antepartum care 4-6 visits

And code 59430 Postpartum care only

And code 59414 Delivery of placenta

With diagnosis 661.3X

Coding Option #4

59899 – Unlisted Procedure maternity care and delivery DX 661.3X

Upon asking multiple coding experts, no one coder agreed on the coding for the delivery.. These 4 options were the ones that were submitted to me. However, the best information that I can suggest is to find out what insurance your patient has (if any) and query them as to how they prefer to have this billed. Bill the scenario based upon how the carrier has informed you. Be sure to include the entire documentation of the precipitous labor and delivery. Good Luck and Happy Coding!