Tips to overcome maternity coding challenges for the inpatient coder
Maternity coding can be a challenge for inpatient coders Understanding what is comprised in obstetric/maternity care is critical to your success in coding and billing those services in the inpatient arena. Obstetric/maternity care is broken down into 3 separate areas
• Antepartum care
• Delivery of the baby(ies)
• Postpartum care
CPT has developed maternity codes that encompass services in a total obstetrical/maternity package, and allows the outpatient coder to bill for the antepartum, the delivery, and postpartum care in 1 CPT code. However, for the inpatient coder, you do not have that “luxury”. ICD-9 does not package those services into a single code set package.
Confusion about the codes is one of the first challenges that a coder has to face as an inpatient coder.
Maternity/obstetric care codes need to be broken down and analyzed as to which codes are appropriate for the services being rendered. Below are the basics for you to know
What procedures and/or services is the hospital providing today?
Appropriate diagnosis allocation (to include 4th and 5th digits)
Auditing the services to ensure correct documentation by the provider to support the procedures billed by your facility
As a coder, when in doubt, always refer to your ICD-9 procedure’s (volume 3) to clarify guidelines and conventions of coding. In Chapter 13 (Obstetrical Procedures) of your ICD-9 Volume 3 Codes 72-75 , will provide you with all the majority of theprocedure codes you will need to bill obstetric/maternity code. , but in addition, you will need to be able to audit the physician documentation to accurately code these claims for your facility.
Codes set 72 includes a forcepts, vaccum and or breech delivery
Codes set 73 includes inductions and assistance procedures during delivery
Codes set 74 includes cesarean sections and the removal of a fetus
Codes set 75 includes other obstetric operations
In addition to the obstetrcal code sets, you also need to be familiar with the codes set from Chapter 12 which include the codes between 65 – 71), It is uncommon, but there are occasions when the obstetric/maternity patient has services provided that fall into the chapter 12 codes.
The key to coding and billing of obstetric/maternity related services, requires good, clear, documentation by the provider or physician, and a good understanding by the coder of what takes place during the maternity stay, to accurately code and bill for those services. The listed services below are normally included in obstetric/maternal services provided by the facility . This is not an all-inclusive list, but gives you an idea of what is involved.
Antepartum Services can include:
o Ultrasound(s)(Obstetric) radiologic services related to obstetrics
o Insertion of a cervical dilator
o External cephalic version
o Fetal biophysical profile
o Administration of Rh immune globulin
o Fetal Non-stress Test (NST)
o Blood Typing/and Rh factors and lab/pathology services related to maternity care
o Fetal non-stress testing
o Management and/or observation care of a chronic, stable illness such as pre-eclampsia, premature labor, diabetes, epilepsy, lupus erythematous or hypertension, Premature rupture of membranes etc//
Delivery Services can include:
Admission to the hospital.
Supervision and/or management of active labor, to include induction services.
Vaginal, and Cesarean delivery.
Delivery of placenta.
Fetal Services and monitoring (such as fetal EKG)
Delivery of the placenta
Repair of uterus, cervix or vagina during delivery
Postpartum care can include
Procedures for post-delivery complications, such as hematoma, or obstetric hemorrhage status post delivery, or retained placenta
services for sterilization
symptoms and complications related to the pregnancy post delivery (i.e. seizures, diabetes, asthsma etc)
In addition to knowing what procedures you need to code for your facility, you also need to have a very good understanding of the diagnosis application to those procedures for maternity/obstetric patients. Again, if you are unsure, always refer to the coding conventions provided at the beginning of your ICD-9 manuals.
Below is a listing of common ob/maternity "complication" diagnoses. This “quick list” gives you an idea of diagnoses and symptoms you may want to be on the look-out for that may place your patient in a “risk” diagnosis area. You should always be on the look-out for diagnoses that have the CC (co-morbidity/complication) designation for your DRG grouper weights. :
– Pre-existing diabetes
– Gestational diabetes mellitus (GDM)
– Pregnancy-induced hypertension or pre-eclampsia
– Fetal anomaly or abnormal presentation (older than or equal to 36 weeks)
– Multiples (i.e. twins)
– Placenta previa
– HIV (or abnormal screen)
– Prior preterm delivery
– Prior preterm labor requiring admission (e.g., early cervical change)
– Intrauterine fetal demise
– Prior cervical or uterine surgery
– Fetal anatomic abnormality
– Abnormal fetal growth
– Preterm labor requiring admission
– Abnormal amniotic fluid
– Recurrent urinary tract infections or stones
– Advanced maternal age (35 yrs or older at EDC)
– Young maternal age (less than 16 yrs at EDC)
– Past complicated pregnancy
In coding and sequencing the diagnoses the 5th digit plays an important part of “telling the story” on your claim. ICD-9 Codes 640-649 and 651-676 require a 5th digit, and the list below denotes the “specific” episode of care. This 5th digit allows a vital understanding of whether or not the patient is in the antepartum, delivery, or postpartum phase of care.
– 0 – Unspecified (Rarely appropriate)
– 1 – Delivered with/without mention of antepartum condition
– 2 – Delivered with mention of postpartum complication
• Verify with supervisor before using these fifth digits in the outpatient clinic: 0-1-2
– 3 – Antepartum condition or complication
– 4 – Postpartum condition or complication
With Ob/Maternity services, sometimes the unexpected happens. You need to know how to code and bill services for miscarriage, ectopic tubal pregnancy, or an ectopic abdominal pregnancy. In these cases, the coder needs to bill the surgical intervention for the miscarriage or ectopic pregnancy. These procedure codes can be found in chapter 12, yet sometimes they are found in Chapter 13..
As you can see below two of the listed codes below are found in chapter 12, yet there are some that are reported from chapter 13.
o 66.62 Salpingectomy with removal of tubal pregnancy
o 69.02 Dilation and curettage following delivery or abortion
o 74.3 Removal of extratubal ectopic pregnancy
Another “big challenge” of OB/maternity coding is multiple gestations. In these cases, coders need to bill for multiple procedures based upon how many times performed, to directly correspond with the amount of babies that are delivered. ( i.e. 2 vaginal deliveries for twins.. Twin A and Twin B) These procedures CAN be different if Twin A is delivered via vaginal with a 72.4 code forceps rotation, and Twin B is delivered with code 72.71 as a vacuum extraction with an episiotomy.,
Last but not least … most hospital coding systems have a DRG grouper that is automated, but you should always check and know how to assign DRG's by hand.
To sum up the entire process for successful coding of inpatient obstetric/maternity care
Understand and Know what encompasses maternity care
Apply the correct procedure codes to the documentation from the provider/physician
Apply the correct diagnosis codes to the procedures (and account for CC’s in your diagnosis application/allocation)
Make sure you have the correct amount of “units” (in the case of multiple gestations)
Double check your DRG groups/grouper that the services are weighted correctly and are grouped In the correct DRG codeset.