What's the deal? - Hospital (ICD-9 Volume 3) Maternity Coding

The blog today covers coding for the hospital based inpatient coder who applies the ICD=9 volume 3 codes in relation to maternity coding. For those of you that code for physician based CPT coding, this will give you an idea of hospital based procedure coding. Enjoy!!!


For Hospital based procedure coding (ICD-9 Volume 3) 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 three separate areas:
• Antepartum care
• Delivery of the baby(ies)
• Postpartum care

The AMA has developed maternity CPT codes that encompass services in a total obstetrical/maternity package. For outpatient coders, this allows them to bill for the antepartum, the delivery, and postpartum care using one CPT code. However inpatient coders don’t have that luxury. ICD-9-CM does not package those services into a single code set.

Confusion about maternity codes often stem from a lack of understanding about which diagnosis and procedure codes are appropriate for obstetric/maternity services Within the ICD-9 code series 630-679 are specific to the “mom” and what is happening to her, and codes 760-779 are for the “fetus/neonate/baby”. It is important to know if you are coding for the “mom” or the “baby”.or both, and apply the correct diagnosis to the service provided. . To ensure that coders get started on the right track, you should have a clear understanding of which procedures and/or services the physician provided on a particular date of service. They should also remember to include fourth and fifth digits for appropriate diagnosis codes.

It’s also important to audit your coding for these services to ensure correct physician documentation of any obstetric/maternal or fetal service to support the procedures. This documentation should include very specific diagnoses, and a descriptive notation of what services were rendered. A good example of this, is when a physician performs AROM (also known as an Artificial Rupture Of Membranes ICD9 procedure code 73.01). The physician should document “how” and “why” the service was performed and for “what” reason. If these basics are missing, you should query your physician to clarify what was performed prior to submitting any claims or billing.

When in doubt, about applying a diagnosis or procedure code, always refer to your ICD-9-CM volume 3 (i.e., procedure codes) to clarify the appropriate application of the official ICD-9 guidelines and conventions of coding for INPATIENT services. In chapter 13 (Obstetrical procedures) of your ICD-9-CM Manual Volume 3, code sets 72–75 cover the majority of the procedure codes you will use to bill obstetric/maternity services. Note the following code categories:

• 72 (Forceps, vacuum, and breech delivery)
• 73 (Other procedures inducing or assisting delivery)
• 74 (Cesarean section and removal of fetus)
• 75 (Other obstetric operations)

In addition to the obstetrical code sets, coders also need to be familiar with code sets 65–71 from chapter 12 (Operations on the female genital organs). It is uncommon, but there are occasions when physicians provide services that fall within chapter 12 codes to obstetric/maternity patients. Note the following code categories:
• 65 (Operations on ovary)
• 66 (Operations on fallopian tubes)
• 67 (Operations on cervix)
• 68 (Other incision and excision of uterus)
• 69 (Other operations on uterus and supporting structures)
• 70 (Operations on vagina and cul-de-sac)
• 71 (Operations on vulva and perineum)

Clear physician documentation and a good understanding by coders of what takes place during the maternity stay are vital for accurate coding and billing of obstetric/maternity related services. Although these are not all-inclusive lists, the services below are normally included in obstetric care.

Antepartum services may include:
• Ultrasound(s) and radiology services related to obstetrics
• Cerclage
• Insertion of a cervical dilator
• Echocardiography
• External cephalic version
• Fetal biophysical profile
• Administration of Rh immune globulin
• Amniocentesis
• Fetal non-stress test (NST)
• Blood typing and Rh factors and lab/pathology services related to maternity care
• Management and/or observation care of a chronic, stable illness (e.g., pre-eclampsia, premature labor, diabetes, epilepsy, lupus erythematosus or hypertension, premature rupture of membranes)

Delivery services may include:
• Admission to the hospital
• Supervision and/or management of active labor, including induction services
• Vaginal or cesarean delivery
• Delivery of placenta
• Episiotomy
• Fetal services and monitoring (e.g., fetal EKG)
• Repair of uterus, cervix, or vagina during delivery

Postpartum care may include:
• Procedures for post-delivery complications (e.g., hematoma, obstetric hemorrhage status post delivery, retained placenta)
• Services for sterilization
• Symptoms and complications related to the pregnancy post-delivery (e.g., seizures, diabetes, asthma)

Coders need to understand the diagnosis that is applicable for procedures performed for maternity care patients. Coders should be on the look-out for certain diagnoses and symptoms that may indicate that a particular patient falls into a “risk” diagnosis area. These diagnoses often include the CC (comorbidity/complication) designation for the DRG grouper weights. Consider the following list of common obstetric/maternity complication diagnoses:

• Pre-existing diabetes 648.0X
• Gestational diabetes mellitus 648.8X
• Pregnancy-induced hypertension or pre-eclampsia 642.4X
• Fetal anomaly or abnormal presentation i.e. 653.5X
• Multiples (i.e. twins) i.e. 651.0X
• Placenta previa 641.0X – 641.1X
• Hypertension642.2X – 642.3X
• HIV (or abnormal screen) 648.9X
• Prior preterm delivery V23.41
• Prior preterm labor requiring admission (e.g., early cervical change) V23.49
• Intrauterine fetal demise 656.4X 632
• Prior cervical or uterine surgery V23.8X
• Fetal anatomic abnormality 655.XX
• Abnormal fetal growth 653.4X
• Preterm labor requiring admission 644.0X – 644.1X
• Abnormal amniotic fluid 657.0X 658.0X
• Bleeding 641.8X
• Anemia 648.2X
• Recurrent urinary tract infections or stones 646.6X
• Advanced maternal age V23.82 659.5X 659.6X(35 years or older at Estimated Date of Confinement (est delivery or due date)
• Young maternal age V23.83 659.8X (Younger than 16 years at EDC)
• Past complicated pregnancy(ies) V23.89 646.8X

In coding and sequencing the diagnoses, the fifth digit plays an important part in telling the story on your claim. ICD-9-CM codes 640–649 and 651–676 require a fifth digit, and the list below denotes the specific episode of care, providing a vital understanding of whether the patient is in the antepartum, delivery, or postpartum phase of care.

• 0: Unspecified
• 1: Delivered with/without mention of antepartum condition
• 2: Delivered with mention of postpartum complication
• 3: Antepartum condition or complication
• 4: Postpartum condition or complication

It is rarely appropriate to report a 0 (Unspecified) for the fifth digit. Verify with a supervisor before using a 0, 1, or a 2 as the fifth digit i Only code an “unspecified code If you do not have enough information or documentation from the provider in the record. As a coder, you should query the physician, or request further physician documentation to accurately diagnosis code the services, rather than use an unspecified code. Unspecified codes can alter the amount of reimbursement you receive from payers. .

When administering obstetric/maternity services, sometimes the unexpected happens. Coders need to know how to assign codes in the event of a miscarriage, ectopic tubal pregnancy, or an ectopic abdominal pregnancy. For these cases, coders need to look to the procedure codes in chapter 12 and sometimes chapter 13. For example, consider billing the following codes for the surgical intervention for the miscarriage or ectopic pregnancy:
• 66.62 (Salpingectomy with removal of tubal pregnancy)
• 69.02 (Dilation and curettage following delivery or abortion)
• 74.3 (Removal of extratubal ectopic pregnancy)

Patients with multiple gestations also present significant coding challenges. For these cases, coders need to bill for multiple procedures based on how many times the physician performs them. This number should correspond directly with the number of babies the physician delivers. For example, you would report two vaginal deliveries for a patient who delivers twins. These procedure codes can be different if twin A is delivered vaginally with code 72.4 (Forceps rotation of fetal head) and twin B is delivered with code 72.71 (vacuum extraction with episiotomy). But if both twins are delivered in the same manner, then you should report the same procedure code x2 to denote the twin delivery.

Below is a vaginal delivery operative note, with possible coding for procedures and diagnoses.
PROCEDURE: Vaginal delivery.
……The patient progressed to delivery of head at the perineum, and was suctioned on the perineum showing a light meconium with patient pushing. The patient would intermittently stop and not push;. However, there was shoulder dystocia. Forceps were used for a DeLee maneuver to rotate the fetal head which seemed somewhat large, (Code 72.4) the forceps again were used with gentle traction on the baby’s head (code 72.0) . There was still some shoulder dystocia. At that point with corkscrew maneuvers, the posterior shoulder was delivered. Once the shoulder was delivered, the rest of the infant was easily delivered. The baby was bulb suctioned. The cord was then clamped, cut, and the baby was handed to the waiting pediatric team. At that time, delivered a male with 6 and 9 Apgars, weight 9 pounds 11 ounces. The placenta was delivered intact with three-vessel cords. Cervix is intact, primary perineal laceration was repaired with 3-0 Vicryl for hemostasis (code 75.69) . Estimated blood loss was 500 cc. The patient did well and the baby was vigorous at five-minute Apgar.
Possible Diagnosis codes for the maternal chart
653.41 Fetopelvic disproportion, delivered (large fetal head)
660.41 Shoulder (girdle) dystocia during labor and deliver, delivered
656.81 Other specified fetal and placental problems affecting management of mother, delivered (meconium)
664.01 First-degree perineal laceration, with delivery
V27.0 Outcome of delivery, single liveborn
Possible diagnosis Codes for the fetal chart:
763.1 Fetus or newborn affected by other malpresentation, malposition, and disproportion during labor and delivery (i.e. shoulder dystocia)
763.2 Fetus or newborn affected by forceps delivery
763.84 Other specified complications of labor and delivery affecting fetus or newborn, Meconium passage during delivery
V30.00 Single liveborn, born in hospital, delivered without mention of cesarean delivery