Saturday, August 7, 2010

Maternity DX sequencing - Question from a reader....

Welcome back to the Blog... and I hope you are all doing well!

This question, came to me from one my wonderful readers. I thought this was a GREAT question. Then I got to thinking that if 1 person has this issue/question, there may be more… so here’s the question, and my response...

Q: “When a patient delivers, I was instructed to append the V27.X (birth status) code as the secondary code, even if there were more maternity codes to be added? I am now confused, as I think that the maternity codes should come first then have the V27.X (birth status) as the last code.”

A: You are correct... I code all pertinent diagnoses for the mom first, then the V27.X (birth status code) My rationale for this: I want to paint the best picture possible to get my "global maternity care" claim paid. I normally code at least 3 dx's for the mom then the 4th diagnosis as the V27.X birth status code.

I have included this reference the coding clinic to help back me up... I "bolded" the areas that apply in the "general rules" Hopefully this will help you out!!!





These guidelines have been developed and approved by the Cooperating Parties in conjunction with the Editorial Advisory Board of Coding Clinic and the American College of Obstetricians and Gynecologists, to assist the coder in coding and reporting obstetric cases. Where feasible, previously published advice has been incorporated. Some advice in these new guidelines may supersede previous advice. The guidelines are provided for reporting purposes. Health care facilities may record additional diagnoses as needed for internal data needs.

1. General Rules

1. Obstetric cases require codes from chapter 11, codes in the range 630-677, Complications of Pregnancy, Childbirth, and the Puerperium.

Should the physician document that the pregnancy is incidental to the encounter than code V22.2 should be used in place of any chapter 11 codes. It is the physician's responsibility to state that the condition being treated is not affecting the pregnancy.

2. Chapter 11 codes have sequencing priority over codes from other chapters.

Additional codes from other chapters may be used in conjunction with chapter 11 codes to further specify conditions.

3. Chapter 11 codes are to be used only on the maternal record, never on the record of the newborn.

4. An outcome of delivery code, V27.0-V27.9, should be included on every maternal record when a delivery has occurred.

These codes are not to be used on subsequent records or on the newborn record.

2. Selection of Principal Diagnosis

1. The circumstances of the encounter govern the selection of the principal diagnosis.

2. In episodes when no delivery occurs the principal diagnosis should correspond to the principal complication of the pregnancy which necessitated the encounter.

Should more than one complication exist, all of which are treated or monitored, any of the complications codes may be sequenced first.

3. When a delivery occurs the principal diagnosis should correspond to the main circumstances or complication of the delivery.

In cases of cesarean deliveries, the principal diagnosis should correspond to the reason the cesarean was performed, unless the reason for admission was unrelated to the condition resulting in the cesarean delivery.

4. For routine prenatal visits when no complications are present codes V22.0,

Supervision of normal first pregnancy, and V22.1, Supervision of other normal pregnancy, should be used as principal diagnoses. These codes should not be used in conjunction with chapter 11 codes.

5. For prenatal outpatient visits for patients with high-risk pregnancies, a code from category V23.x

Supervision of high-risk pregnancy, should be used as the principal diagnosis. Secondary chapter 11 codes may be used in conjunction with these codes if appropriate. A thorough review of any pertinent excludes note is necessary to be certain that these V codes are being used properly.

3. Chapter 11 Fifth-digits

1. Categories 640-648, 651-676 have required fifth-digits which indicate whether the encounter is antepartum, postpartum and whether a delivery has also occurred.

2. The fifth-digits which are appropriate for each code number are listed in brackets under each code.
The fifth-digits on each code should all be consistent with each other. That is, should a delivery occur all of the fifth-digits should indicate the delivery.

4. Fetal Conditions Affecting the Management of the Mother.

Codes from category 655, Known or suspected fetal abnormality affecting management of the mother, and category 656, Other fetal and placental problems affecting the management of the mother, are assigned only when the fetal condition is actually responsible for modifying the management of the mother, i.e., by requiring diagnostic studies, additional observation, special care, or termination of pregnancy. The fact that the fetal condition exists does not justify assigning a code from this series to the mother's record.

5. Normal Delivery, 650

1. Code 650 is for use in cases when a woman is admitted for a full-term normal delivery and delivers a single, healthy infant without any complications antepartum, during the delivery, or postpartum during the delivery episode.

2. 650 may be used if the patient had a complications at some point during her pregnancy but the complication is not present at the time of the admission for delivery.

3. Code 650 is always a principal diagnosis.

It is not to be used if any other code from chapter 11 is needed to describe a current complication of the antenatal, delivery, or perinatal period. Additional codes from other chapters may be used with code 650 if they are not related to or are in any way complicating the pregnancy.

4. V27.0, Single liveborn, is the only outcome of delivery code appropriate for use with 650.

6. Procedure Codes

1. In cases of cesarean delivery, the selection of the principal diagnosis should correspond to the reason the cesarean delivery was performed unless the reason for admission was unrelated to the condition resulting in the cesarean delivery.

2. A delivery procedure code should not be used for a woman who has delivered prior to admission to the hospital. Any postpartum repairs should be coded.

7. The Postpartum Period

1. The postpartum period begins immediately after delivery and continues for 6 weeks following delivery.

2. A postpartum complication is any complication occurring within the 6 week period.

3. Chapter 11 codes may also be used to describe pregnancy-related complications after the 6 week period should the physician document that a condition is pregnancy related.

4. Postpartum complications that occur during the same admission as the delivery are identified with a fifth digit of 2". Subsequent admissions for postpartum complications should identified with a fifth digit of 4".

5. When the mother delivers outside the hospital prior to admission and is admitted for routine postpartum care and no complications are noted, code V24.0, Postpartum care and examination immediately after delivery, should be assigned as the principal diagnosis.

8. Abortions (Missed, Spontaneous, etc)

1. Fifth-digits are required for abortion categories 634-637. Fifth-digit 1, incomplete, indicates that all of the products of conception have not been expelled from the uterus. Fifth-digit 2, complete, indicates that all products of conception have been expelled from the uterus prior to the episode of care.

2. A code from categories 640-648 and 651-657 may be used as additional codes with an abortion code to indicate the complication leading to the abortion.

3. Fifth digit 3 is assigned with codes from these categories when used with an abortion code because the other fifth digits will not apply. Codes from the 660-669 series are not to be used for complications of abortion.

4. Code 639 is to be used for all complications following abortion. Code 639 cannot be assigned with codes from categories 634- 638.

5. Abortion with Liveborn Fetus. When an attempted termination of pregnancy results in a liveborn fetus assign code 644.21, Early onset of delivery, with an appropriate code from category V27, Outcome of Delivery. The procedure code for the attempted termination of pregnancy should also be assigned.

6. Retained Products of Conception following an abortion. Subsequent admissions for retained products of conception following a spontaneous or legally induced abortion are assigned the appropriate code from category 634, Spontaneous abortion, or legally induced abortion, with a fifth digit of รด1" (incomplete). This advice is appropriate even when the patient was discharged previously with a discharge diagnosis of complete abortion.

9. Code 677, Late effect of complication of pregnancy, childbirth, and the puerperium

1. Code 677, Late effect of complication of pregnancy, childbirth, and the puerperium is for use in those cases when an initial complication of a pregnancy develops a sequelae requiring care or treatment at a future date.

2. This code may be used at any time after the initial postpartum period.

3. This code, like all late effect codes, is to be sequenced following the code describing the sequelae of the complication.