Sunday, January 3, 2016

Q&A follow-up (part 1) Unbundling the OB Package in ICD-10-Clinical Documentation

Q&A follow-up (part 1)  Unbundling the OB Package in ICD-10-Clinical Documentation

This is a 2-part series of Q&A that was sent in by our listeners of  the Webinar for the HCPro webinar I did entitled " Unbundling the Pregnancy Package in ICD-10"   This can be purchased from HCPro and includes some GREAT information!  (which includes clinical documentation requirements).  We had some great questions, but ran out of time during the Webcast and felt this would be the perfect forum to address those questions, we were unable to during the show. 

As we continue to learn and embrace ICD-10cm, many coders are still feeling uncertain in their ability to code OB delivery and ancillary services as easily as we did the ICD-9.  ICD-10cm has presented some new documentation challenges.  The first 8 Q&A questions are address below.

Q1. During the delivery if the physician documents group B strep positive on the delivery note, do you code O99.824, Z3A.XX, and weeks of gestation?

A1.  Yes, this is proper coding for the GBS notation, however, there also needs to be documentation that this was “complicating” the pregnancy.   A positive GBS culture is considered a pregnancy complication, it is not considered a high-risk pregnancy complication.  Within the documentation the provider should have notated the care associated with GBS, such as the usage of antibiotics prior to or during the delivery itself.  

If the provider notes that the patient is a GBS carrier, or does not consider this to be a complication of the pregnancy, then the code Z22.330 Carrier of Group B streptococcus should be used rather than a “complication” code.   As a coder, if it is unclear whether the provider is considering GBS a complication at the time of delivery, a query may be in order to clarify.
Rationale:  16. Documentation of Complications of Care; Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented.[1]

Q2.  In ICD-10 in references the Z3A.XX "weeks of gestation" code for the "weeks" of delivery.  Do we have to put this on every single encounter?
A2.  According to AHIMA, the Z3A.XX weeks of gestation code do not have to be appended at every single encounter.  However this provides an amazing amount of information and data tracking, not only for your office, but also as transparency for the patient, the payer and the physician.  It is incredibly helpful to see that the patient had their 1st trimester ultrasound at 11 weeks, just by reviewing the claim and/or patient data.

Q3.  What code are you using when there is a current condition that the mother has, e.g., rheumatoid arthritis?

A3.  Upon delivery if the patient has another current condition that is affecting the delivery itself, it is appropriate to code the sign, symptom, or diagnosis, however, the documentation in a delivery record needs to clearly state whether or not it is a “complication” to the pregnancy, or simply a co-existing medical diagnosis.    In the case above where it is referenced the mother has rheumatoid arthritis, but does not notate a “complication” and the patient has a non-complicated birth, the usage of codes below could be considered.
O80 Encounter for full-term uncomplicated delivery
Rheumatoid arthritis, unspecified
Z37.X (birth status)
Z3A.XX (weeks of gestation)

However, if the provider is documenting that the mothers’ rheumatoid arthritis is currently complicating the pregnancy and/or delivery, then the ICD-10 codes could be considered based upon the providers actual documentation/or query

O26.89X Other specified pregnancy related conditions
M06.9 Rheumatoid arthritis, unspecified (or more specificity regarding the RA)
Z37.X (birth status)
Z3A.XX (weeks of gestation)

Rationale:   c. Pre-existing conditions versus conditions due to the pregnancy; Certain categories in Chapter 15 distinguish between conditions of the mother that existed prior to pregnancy (pre-existing) and those that are a direct result of pregnancy. When assigning codes from Chapter 15, it is important to assess if a condition was pre-existing prior to pregnancy or developed during or due to the pregnancy in order to assign the correct code. Categories that do not distinguish between pre-existing and pregnancy-related conditions may be used for either. It is acceptable to use codes specifically for the puerperium with codes complicating pregnancy and childbirth if a condition arises postpartum during the delivery encounter.[2]

Q4. What if circumcision is done during delivery? Bill that on a separate claim for infant? Is this a covered procedure?

A43.   In many cases the OB/GYN does do a circumcision on the baby during the delivery hospital stay.  If that provider does perform the circumcision, the patient should receive a charge/billing for that service provided.  The circumcision code will be billed on the infant’s claim with the appropriate CPT code, and under the OB/Gyn provider who performed the procedure.   Many third party insurance carriers do not cover routine circumcision as a covered benefit, so reimbursement may fall to the patient for the entire charge. 
54150 Circumcision, using clamp or other device with regional dorsal penile or ring block
54160 Circumcision, surgical excision other than clamp, device or dorsal slit, neonate (28 days of age or less)
ICD-10 Z41.2 Encounter for routine and ritual male circumcision

Q5. Would you bill with a modifier -51 or -59 for the second baby?

A5.  According to the 2015 ACOG coding manual; If vaginal delivery of twins is performed, report CPT code 59400 and 59409-59 or code 59409 with other appropriate X{EPSU}
sub-modifier per payer policy[3]

The rationale behind this is you have provided only 1 antepartum care for 1 patient (mom)  However, there were 2 fetus’ and you had separately identifiable delivery for 2 fetus’.  Therefore, a global charge of code 59400 is for baby “A”, and a delivery only charge with the appending of mod 59 for baby “B”. 

Q6.  If patient is admitted to hospital for complication in second trimester how do we indicate this is not delivery so that when the patient delivers we are not denied for it being already paid as part of the global?

A6.  When you are billing for your complication in second/third trimesters and the patient is still pregnant (undelivered) the ICD-10cm diagnosis codes appended will document this.  If and when the patient actually delivers you will append the “Outcome of delivery” codes to the claim, as per the ICD-10 coding guidelines.

Rationale:  Outcome of delivery;  A code from category Z37, Outcome of delivery, 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.  [4]

Outcome of delivery Z37- This category is intended for use as an additional code to identify the outcome of delivery on the mother's record. It is not for use on the newborn record.
Type 1 Excludes stillbirth (P95
 Z37 Outcome of delivery Z37.0 Single live birth Z37.1 Single stillbirth Z37.2 Twins, both liveborn Z37.3 Twins, one liveborn and one stillborn Z37.4 Twins, both stillborn Z37.5 Other multiple births, all liveborn Z37.50 Multiple births, unspecified, all liveborn Z37.51 Triplets, all liveborn Z37.52 Quadruplets, all liveborn Z37.53 Quintuplets, all liveborn Z37.54 Sextuplets, all liveborn Z37.59 Other multiple births, all liveborn Z37.6 Other multiple births, some liveborn Z37.60 Multiple births, unspecified, some liveborn Z37.61 Triplets, some liveborn Z37.62 Quadruplets, some liveborn Z37.63 Quintuplets, some liveborn Z37.64 Sextuplets, some liveborn Z37.69 Other multiple births, some liveborn Z37.7 Other multiple births, all stillborn Z37.9 Outcome of delivery, unspecified

Q7.  In ICD-1cm can you bill code 035.3X Maternal care for suspected damage to fetus from drug and code 099.33X Smoking (tobacco) complicating pregnancy, childbirth, and the puerperium at the same encounter?     What about code O99.32X Drug use complicating pregnancy, childbirth, and the puerperium?

A7.  In ICD-10 pay close attention to what the code is actually stating and look at the “key verbiage” within the codeset.

Usage of code O35.3X Maternal Care for suspected damage to fetus from drug, denotes that the provider is concerned with care provided to the mom, due to “suspected” damage to the fetus from drug.   Eg..  the provider may need the mom to have a higher intensity ultrasound of the fetus, or have alternative prescription or social work intervention for a suspected issue with the fetus.

Usage of the code O99.33X is for usage where smoking (tobacco) is specifically noted that the mothers’ usage of tobacco is complicating her pregnancy care and oversight.  Usage of the code O99.32X is for usage where drug usage by the mother (this can be any type of drug, eg prescription necessitated, over the counter, herbal, legal, illegal)  again is complicating the pregnancy care.   

All three of these codes can be coded together, however, when coding O35.3X the provider is required to document the “suspicion” that there may be damage to the fetus from the usage of a particular drug.  (eg.  Pregnancy and patient is currently prescribed drugs for a seizure disorder that may be harmful to a fetus).


Q8 When twins are born cesarean on different dates (eg past Midnight) How do I bill for this?  

A8.  In this instance, the cesarean procedure date/time will be noted for your claim, and with a twin cesarean, the modifier 22 will be appended for the "mothers" record, and it will look similar to this:

CPT:      59514-22 (twin cesarean delivery)
ICD-10 O82.0 Encounter for cesarean delivery without indication
 Z37.2 Twins, both liveborn
 Z3A.XX Weeks of gestation

However, if Twin A is born at 11:58p.m.  and Twin B is born at 12:02 a.m. (next day)  the babies records will be denoted with the two different dates.   The insurance carrier MAY deny this, so be prepared to submit records with this type of claim.  On each of the baby’s records the Date of Service should correspond to the actual date of delivery.   

Q9  In regard to fetal non-stress tests (FNST/NST) , if the physician has not done an interpretation but two RNs have reviewed and documented it, can the hospital facility fee be charged?
A9.   The answer to the above is “yes”.  The rationale is the hospital owns the FNST/NST equipment and all equipment/ supplies must be billed for when used in the facility.  The physician bears the responsibility of doing the interpretation of the test, and documenting the medical necessity/indicator for the testing procedure.  The RN’s that reviewed the test, their responsibility lies in getting the service for the usage of the equipment posted in the chargemaster so it will bill out.

Q10  Would you code Category ll or Category  lll fetal heart tones if mentioned in the delivery chart?  What is documented to show this affects the management of the mother?

A11.  In regard to the actual ICD-10cm coding for a Category II or Category III fetal heart tracing lies in what the provider has actually documented.  The ICD-10cm codes do not correspond do the verbiage “category II or category III”.  ICD-10cm does have codes to represent abnormalities in fetal heart rate and fetal stress.   These codes are found in the code range O76 – O77.9

It is the providers’ duty to provide appropriate documentation of the FNST, and needs to include the medical necessity for the testing (eg diagnosis) .  The clinical documentation from the provider must also support the findings if the testing is noted as a category I, II, or III strip, and how management of the patient is impacted due to the findings within the test.    

According to the guidelines for OBG management and clinical documentation,  A Category I tracing is characterized by a FNST/NST or FHR (Fetal Heart Rate)  tracing, during labor (continuous or intermittent) as:
Category I definition:
·         baseline rate of 110–160 beats/min
·         moderate variability
·         no late or variable decelerations
·         early decelerations being present or absent
·         accelerations being present or absent.

A Category II tracing definition is given to all FHR patterns that cannot be assigned to Category I or Category  III.   A Category II tracing is neither normal nor definitively abnormal.
Category II definition
·         If FHR accelerations or moderate variability are detected, the fetus is unlikely to be currently acidemic.
·         If fetal heart accelerations are absent and variability is absent or minimal, the risk of fetal acidemia increases.
·         Category II tracings should be monitored closely and evaluated carefully.

A Category III tracing shows a clearly abnormal tracing, and is associated with increased risk of fetal acidemia, neonatal encephalopathy, and cerebral palsy.
A Category III tracing is characterized by
·         absent variability plus any one of the following:
    • recurrent late decelerations
    • recurrent variable decelerations
    • bradycardia.
Recurrent late or variable decelerations are defined as those decelerations that occur with 50% or more of contractions. A sinusoidal pattern—characterized by a smooth, sine wave-like, undulating pattern with a cycle frequency of 3–5 waves/min that persists for 20 minutes or longer is also classified as a Category III tracing.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC 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 or you can also find current coding information on her blog site:

[1] ICD-10-CM Official Guidelines for Coding and Reporting FY 2016 Page 16 of 115
[2] ICD-10-CM Official Guidelines for Coding and Reporting FY 2016 Page 54 of 115
[3] ACOG 2015 coding manual  page 423
[4] ICD-10-CM Official Guidelines for Coding and Reporting FY 2016 Page 54 of 115

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