Finding clarity in coding of fetal status

Finding clarity in coding of fetal status

Lori-Lynne A. Webb

February 27, 2015

The term “fetal distress” can be very misleading when coding for pregnancy related complications that involve the fetus.  Unfortunately, in the OB/Gyn specialty the term “Fetal distress” is widely used, but is very misleading.  The definition: of fetal distress in medical dictionaries note it as: “An abnormal condition of a fetus during gestation or at the time of delivery; marked by altered heart rate or rhythm and leading to compromised blood flow or changes in blood chemistry.”  With this in mind, clarification of fetal diagnosis(es) or symptoms documented in the medical record by the provider is extremely important. 

Medical providers even have a difficult time with the term “fetal distress”.  The vagueness of the definition forces the providers to develop their own criteria rely on personal experience to decide if and when a fetus is in jeopardy.  The American College of Obstetricians and Gynecologists (ACOG) has weighed in on this issue, and suggests that physicians use the more descriptive "nonreassuring fetal heart rate tracing." However,  many providers still use the term “fetal distress” rather than give a more definitive description of the fetal symptoms.

ICD-9 has not done coders any favors in their definition of fetal distress.  (eg fetal metabolic academia) as shown below

656.31 Fetal distress affecting management of mother – Delivered

656.33 Fetal distress affecting management of mother – Antepartum

656.3X Excludes:

abnormal fetal acid-base balance (656.8x)

abnormality in fetal heart rate or rhythm (659.7x)

fetal bradycardia (659.7x)

fetal tachycardia (659.7x)

meconium in liquor (656.8x)

*note, codes in this category all require a 5^th digit for correct diagnosis reporting

ICD-10 does a better job in requiring specificity of the fetal symptom (antepartum maternal issue) than ICD-9 does.  When looking at the cross references for the “fetal distress”  ICD-10 leads the coder to the code section of O68.  The example below shows the specificity of the abnormal fetal acid base balance, rather than just “fetal distress”.  ICD-10  is much more specific when cross referencing the more specific abnormality in fetal heart rate or rhythm; as ICD-9 specifies it under code 659.7x.

O68 Labor and delivery complicated by abnormality of fetal acid-base balance

Fetal acidemia complicating labor and delivery

Fetal acidosis complicating labor and delivery

Fetal alkalosis complicating labor and delivery

Fetal metabolic acidemia complicating labor and delivery

Excludes1:

Fetal stress NOS (O77.9)

Labor and delivery complicated by electrocardiographic evidence of fetal stress (O77.8)

Labor and delivery complicated by ultrasonic evidence of fetal stress (O77.8)

Excludes2:

Abnormality in fetal heart rate or rhythm (O76)

Labor and delivery complicated by meconium in amniotic fluid (O77.0)

When it comes to finding a code for abnormal or non-reaassuring fetal heart rate  (FHR)  ICD-9 does present better choices of descriptive codes to work with.  ICD-9 code 659.7X Abnormality in fetal heart rate or rhythm specifically states abnormality in the code description.  Within code 659.7X,  not only do we have the abnormality verbiage, but also verbiage such as Non-reassuring fetal heart rate, Fetal tachycardia, Fetal bradycardia and Fetal heart rate decelerations.  Physicians and clinical providers can help coders by ensuring their clinical documentation includes clear descriptive and specific verbiage information in regard to fetal and maternal status. 

In the list below, the following terms may be linked to abnormal or non-reassuring FHR’s.

o   Nonreassuring FHR patterns

o   Fetal tachycardia

o   Fetal bradycardia

o   Saltatory variability

o   Variable decelerations associated with a non-reassuring pattern

o   Late decelerations with preserved beat-to-beat variability

o   Ominous patterns

o   Persistent late decelerations with loss of beat-to-beat variability

As a coder, you may be challenged to understand what each of these terms mean, but if your provider is willing to document this information up-front, this makes the coding of fetal status much easier and more clearly identifiable.  The fetal heart rate or FHR is normally determined via the Fetal Non-Stress Test (NST/FNST).  A Fetal NST is a non-invasive test that can be performed by clinical personnel, then interpreted and the findings noted in the chart regarding the findings based on the heart-rate strip generated by a recording of the fetal heart rate over a period of a minimum 20 minutes.   These strips that look similar to an EKG strip and their determination falls into 1 of 3 tiered categories. 

Category I : Normal.

The fetal heart rate tracing shows ALL of the following:

Baseline FHR 110-160 BPM, moderate FHR variability, accelerations may be present or absent, no late or variable decelerations, may have early decelerations. May be considered a reactive fetal non-stress test

Strongly predictive of normal acid-base status at the time of observation. Routine care.

Category II : Indeterminate.

The fetal heart rate tracing shows ANY of the following:

Tachycardia, bradycardia without absent variability, minimal variability, absent variability without recurrent decelerations, marked variability, absence of accelerations after stimulation, recurrent variable decelerations with minimal or moderate variability, prolonged deceleration > 2minutes but less than 10 minutes, recurrent late decelerations with moderate variability, variable decelerations with other characteristics such as slow return to baseline, and "overshoot".

Not predictive of abnormal fetal acid-base status, but requires continued surveillance and reevaluation. 

Category III: Abnormal.

The fetal heart rate tracing shows EITHER of the following:

Sinusoidal pattern OR absent variability with recurrent late decelerations, recurrent variable decelerations, or bradycardia.

Predictive of abnormal fetal-acid base status at the time of observation. Depending on the clinical situation, the provider of care should make efforts to emergently resolve the underlying cause of the abnormal fetal heart rate pattern.

In the documentation from the physician or provider, the notes should clearly state the category of the fetal status, and the diagnosis(es) to correlate with it.  (eg tachycardia, bradycardia).  ICD-9 gives us the codes of 659.7X.  ICD-10 will cross reference into the codes O76 and 077.XX (see below)

O76 Abnormality in fetal heart rate and rhythm complicating labor and delivery Depressed fetal heart rate tones complicating labor and delivery

Fetal bradycardia complicating labor and delivery

Fetal heart rate decelerations complicating labor and delivery

Fetal heart rate irregularity complicating labor and delivery

Fetal heart rate abnormal variability complicating labor and delivery

Fetal tachycardia complicating labor and delivery

Non-reassuring fetal heart rate or rhythm complicating labor and delivery

Excludes1:       fetal stress NOS (O77.9)

labor and delivery complicated by electrocardiographic evidence of fetal stress (O77.8)

labor and delivery complicated by ultrasonic evidence of fetal stress (O77.8)

Excludes2:       fetal metabolic acidemia (O68)

other fetal stress (O77.0-O77.1)

O77 Other fetal stress complicating labor and delivery

O77.0 Labor and delivery complicated by meconium in amniotic fluid

O77.1 Fetal stress in labor or delivery due to drug administration

O77.8 Labor and delivery complicated by other evidence of fetal stress

Labor and delivery complicated by electrocardiographic evidence of fetal stress

Labor and delivery complicated by ultrasonic evidence of fetal stress

Excludes1: abnormality of fetal acid-base balance (O68)

O77.9 Labor and delivery complicated by fetal stress, unspecified

Excludes1: abnormality of fetal acid-base balance (O68)

       abnormality in fetal heart rate or rhythm (O76)

       fetal metabolic acidemia (O68)

Now that we’ve explored the differences in what the diagnoses mean, and the ICD-9 and ICD-10 codes that correlate with it, let’s look at some documentation examples.

Example #1

Ms. L is a 38-year-old gravida 5, para 3, white female patient of Dr. Hero at 36-4/7 weeks' gestation who presents to the L&D ER complaining of uterine contractions.  They are anywhere from 4-10 minutes apart and are mild to moderate.  She denies any leaking fluid or ruptured membranes or bleeding.  She has had no problems with this pregnancy except that her blood pressure has been running somewhat high throughout her pregnancy with systolics in the 140s on numerous occasions and is correlated to gestational HBP.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Afebrile, vital signs stable.  BP 141/79 
GENERAL:  The patient is a well-developed, well-nourished, female in no acute distress.
ABDOMEN:  Soft.  Uterine contractions are present about every 4-6 minutes.  
PELVIC:  Cervix is very posterior, -2 station, 50% and tight 2 cm, unchanged after walking for an hour.

Fetal heart tones show moderate variability, 15 x 15 accelerations and no decelerations with a baseline of 145.Category 1 FNST – no fetal stress noted.

ASSESSMENT:
False labor in an elderly multigravida/multiparous patient at 36-4/7 weeks' gestation with known pregnancy related HBP and reassuring  with a category 1 FNST

PLAN:
Patient was given labor instructions.  She will be calling Dr. Hero's office later in the day to get a refill on her Norco, Fioricet and labeletol.  She does not want anything else from us now. Patient discharged in good condition  from Emergency L&D.

ICD-9 Diagnoses:

644.03    Threatened premature labor prior to 37 weeks

659.63  Elderly multigravida, with antepartum condition or complication

642.33  Transient hypertension of pregnancy, antepartum

ICD-10 Diagnoses:

O60.03  Preterm labor without delivery, third trimester

O09.523 Supervision of elderly multigravida, third trimester

O13.3 Gestational [pregnancy-induced] hypertension without significant proteinuria, third trimester

The clinical rationale and medical necessity for performing the fetal non-stress test is due to the above diagnoses.  We will not code any “fetal stress” as the testing was normal.

Example #2

Chief Complaint: Preterm Labor at 33 4/7 wks (inpatient setting)

Patient  reports increased contractions this morning after an uneventful night. Contractions are once again resolving after Nubain. She received her 2nd BTMS dose this am at 0500. She denies leaking, bleeding or decreased fetal movement. She is on 2 gm/hr of magnesium and tolerating this better than the 3 gm/hr she had been on previously.

Afebrile. Normotensive. Lungs: CTAB  CV:RRR

Abd: +BS. No guarding or rebound.

Pelvic: Cx 5/80/-3, slightly improved over yesterday.

Ext: No cords.

Fetal monitoring: Toco w irregular contractions. FHR baseline 130 with 15x15 accelerations, occasional decelerations and tachycardia with moderate variability, Category II non-stress test

Pt is a G3P0111 at 33 4/7 wks with advanced cervical dilation and preterm labor and fetal tachycardia.

Continue magnesium for tocolysis until 48 hours of BTMS and then discontinue. Continue to monitor fetus closely. Plan for possible preterm delivery in light of continued cervical change and dilation. NICU aware.

ICD-9 Diagnoses:

644.03             Threatened premature labor prior to 37 weeks

659.73             Abnormality in fetal heart rate or rhythm, antepartum condition or complication

ICD-10 Diagnoses:

O60.03                        Preterm labor without delivery, third trimester

O76                 Abnormality in fetal heart rate and rhythm complicating labor and delivery

Rationale:  Clear documentation of the threatened premature labor, and notation of a category II fetal non stress test that documents fetal tachycardia . 

In conclusion, coders need to carefully review the clinical documentation for clear guidance of fetal diagnosis in relation to the visit, regardless if patient is inpatient status or outpatient status.  If the documentation regarding fetal status is not readily apparent, then a query to the physician is necessary to determine the appropriate diagnosis for fetal status. 

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , CDIP, and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.