Coding
Complications of Pregnancy:
Hypertension, Pre-eclampsia, Eclampsia and ICD-10
Hypertension is dangerous during pregnancy because it may
interfere with the placenta's ability to deliver oxygen and nutrition to the
fetus and has also been noted to be a contributing factor in low-birthweight babies. Pregnant patients may have other health
problems too, such as gestational diabetes, that can contribute to the complexity of the
pregnancy. These pregnancy complication may
necessitate a patient be induced for delivery prior to the “normal” timeframe
of 38-40 weeks of gestation. If induced
for delivery, the patient will be
closely monitored for a vaginal, or if more complications arrise, be delivered
via cesarean section.
Women with hypertension in pregnancy have a higher risk
of complications such as:
·
Abruptio placentae. (Placental abruption)
·
Cerebrovascular accident. (CVA)
·
Disseminated intravascular coagulation. (DIC)
The fetus has an increased risk of:
·
Intrauterine growth restriction. (IUGR)
·
Prematurity.
·
Intrauterine death.
As you can see in the table below, ICD-10cm gives us
these codes to be used when hypertension is a factor in pregnancy, childbirth
and the puerperium.
O10 Pre-existing
hypertension complicating pregnancy, childbirth and the puerperium
O11 Pre-existing
hypertension with pre-eclampsia
O12 Gestational
[pregnancy-induced] edema and proteinuria without hypertension
O13 Gestational
[pregnancy-induced] hypertension without significant proteinuria
O14 Pre-eclampsia
O15 Eclampsia
O16 Unspecified
maternal hypertension
As we can see, not only do coders have to choose the
correct code, the providers need to give good clear documentation for the
coders to choose from. However, before
we can correctly choose these codes, we need to have a good working knowledge
of what the definitions are of the pregnancy hypertensive code-set. Unfortunately , the cause of pre-eclampsia is
still unknown.
Pre-existing hypertension is defined as:
·
a systolic blood pressure (BP) of 140 mm Hg or
greater,
·
and/or a diastolic BP of 90 mm Hg or more,
·
either pre-pregnancy or before 20 weeks
Gestational hypertension (aka pregnancy-induced
hypertension)
·
Is the development of a new hypertension
diagnosis in a pregnant woman after 20 weeks gestation without the
presence of protein in the urine or other signs of preeclampsia.
·
Can be considered severe when systolic blood
pressure is ≥160 mmHg and/or diastolic blood pressure is ≥110 mmHg on two
consecutive blood pressure measurements at least four hours apart
Preeclampsia is defined as:
·
A condition in pregnancy characterized by abrupt
hypertension (a sharp rise in blood pressure),
·
Albuminuria (leakage of large amounts of the
protein albumin into the urine)
·
Edema (swelling) of the hands, feet, and face
·
A headache that will not go away
·
Seeing spots or changes in eyesight
·
Pain in the upper abdomen or shoulder
·
Nausea and vomiting (in the second half of
pregnancy)
·
Sudden weight gain
·
Difficulty breathing
·
Severe hypertension and signs/symptoms of
end-organ injury are considered within the severe spectrum of the pre-eclampsia
disease process.
o Note: In 2013, the American College of
Obstetricians and Gynecologists (ACOG) removed proteinuria as an essential
criterion for diagnosis of preeclampsia with severe features.
Eclampsia is defined as:
·
The development of grand mal seizures in a
pregnant patient with diagnosed pre-eclampsia, (in the absence of other
neurologic conditions that could account for the seizure activity)
HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low
Platelets) is commonly defined as :
·
a severe form of pre-eclampsia, OR
·
HELLP syndrome can be considered an independent
disorder from pre-eclampsia based upon the providers documentation)
Preeclampsia affects 3% to 5% of all pregnancies and any
pregnant woman can get preeclampsia, but studies have shown that a patient is
at a higher risk of pre-eclampsia if the provider has noted any of these risk
factors:
·
This is the first pregnancy
·
A family history where the patient’s mother or
sister had preeclampsia or eclampsia during pregnancy
·
Patient is pregnant with a multiple gestation
(eg: twins, triplets)
·
Patient is under age 20 or over age 40 at the
time of pregnancy
·
The patient has a pre-existing diagnosis of high
blood pressure, kidney disease, or diabetes
·
The patient has a pre-pregnancy body mass index
(BMI) greater than 30 (potential obesity)
·
The patient was diagnosed with preeclampsia in a
previous pregnancy
What to look
for clinically – to choose the correct codes in ICD-10
Now that we are fully entrenched in ICD-10 coders will
need to look for the above and verify that the provider has clearly stated the
diagnosis when coding for a pregnant patient with symptoms of hypertension
and/or pre-eclampsia. If only the
symptoms are noted, it is warranted to then query the physician and ask if the
symptoms correlate to a specific diagnosis, or are simply “separately
identifiable” signs and symptoms.
Clinical Emergency
Department Note:
HPI: 41-year female, G2P0A1, at 36 and 3/7 weeks, presents to the Emergency room with sever
headache and confusion. Husband and
mother both report that the patient has had episodes of muddled thinking for
last ten days or more. Pregnancy has
been uneventful. While in the Emergency
Department, the pt complains of
bilateral pulsing headache with no visual disturbances. Headache is aggravated
with any movement and has not responded to Tylenol. Pt has had nausea x 3 days, no vomiting, but
has symptoms of oliguria. Pt states “Cannot remember when I last
urinated”. ROS includes RUQ pain.
Patient reports good fetal movement, denies contractions, vaginal bleeding,
or pelvic cramping. Patient also denies dizziness, loss of coconsciousness,
tremors, seizures, SOB, chest pain.
Patient denies tobacco, alcohol, or drug use. Patient states she took Tylenol 2 hrs ago,
but without relief of headache.
Physical Exam:
Vital Signs: BP 142/94, T
98.9°F, P 94, R 22. Ht: 5’ 0” Wt: 151 lb.
Well nourished, well-groomed,
A&Ox3, mood distressed.
HEENT, Respiratory and Cardiac
exams all normal.
Abdomen: Fundal height
consistent with 36 weeks, single fetus, vertex and engaged; fetal weight ~
2,200g, FHR 142 bpm. Fetus small for gestational age.
Musculoskeletal: Adequate muscle
tone + full AROM x4. Deep tendon reflexes were 4+/4+ with sustained knee and
ankle clonus.
Extremities: Generalized edema
present, 3+ bilateral edema LE. No cyanosis.
Vaginal exam: Cervix fingertip
dilated and 5% effaced. The vertex was presenting at 0 station. Membranes
intact. Laboratory: U/A 3+ proteinuria +2 glucose
Assessment/Plan:
Severe pre-eclampsia. Will obtain
Fetal ultrasound with bio-physicial profile and fetal non-stress test to assess
fetal status. Proceed with Direct admit
to Labor and Delivery unit for induction of labor. Admission orders: called and faxed to L&D
unit nurse. Will contact patient’s
primary OB to meet the patient at L&D and assume care for induction of
labor in a pre-eclamptic advanced maternal age patient.
*****************************************************************************************
Operative Note:
Indication: 41-year-old patient that has been admitted to
Labor and Delivery unit for induction of labor due to Severe
pre-eclampsia. Induction attempted with IV
Pitocin, but patient failed to progress. Fetus is cephalic per bedside
ultrasound, and we will proceed with low transverse c/s
Patient was prepared and draped in the usual manner. Incision was made as noted above and carried
down through the subcutaneous tissue, muscular fascia and peritoneum. Once
inside the abdominal cavity, a low cervical transverse incision was made in the
lower uterine segment after creating a bladder flap by both blunt and sharp
dissection. With creation of the bladder flap, a transverse incision was made
and the infant was delivered as a vertex. The placenta was removed and appeared
normal w/3 vessel cord, cord blood was obtained. The infant was handed off to the
nurses in attendance. The uterus was then exteriorized and brought out through
the abdominal incision. We then closed the uterine incision in the usual manner
with #1 Chromic suture in a running continuous manner. The bladder flap was
inspected for hemostasis and closed with #2-0 Chromic in a running continuous
manner as well. Number 0 Vicryl was used to close the fascia in a running
continuous manner. The subcutaneous tissue and peritoneum were closed with #2-0
Vicryl suture in a running continuous manner. The skin was closed as noted
above. Foley catheter inserted. Clear urine was noted. The sponge count was
correct times 2. There were no complications.
Estimated blood loss was 600 cc.
Delivery of live male infant weighting 5 pounds 1oz having Apgar’s of 7
at one minute and 9 at five minutes. The patient was then awakened and taken to
the Recovery Room in good condition
CPT Procedure
Coding considerations for the above include:
A)
Coding and Billing for the Emergency Department
visit (99281 – 99285)
B)
Coding and Billing for the Cesarean and/or
Global Delivery Care by OB (Depending on
care delivered)
a. 59510 Routine obstetric care including antepartum
care, cesarean delivery, and postpartum care (Global Service)
b. 59514 Cesarean delivery only;
c. 59515 Cesarean delivery only; including postpartum
care
ICD10 pcs
Procedure Coding Consideration
10D00Z1 Extraction, Products of
Conception, Low Cervical cesarean section
ICD-10 cm
Diagnosis Coding considerations include:
O14.13 Severe pre-eclampsia,
third trimester
O61.0 Failed medical or unspecified induction of
labor, delivered, with or without mention of antepartum condition
O09.513 Supervision of
high-risk pregnancy with elderly primigravida third trimester N/A
Z3A.36 36 Weeks gestation
Z37.0 Single live birth
Coding Wrap up
In the clinical documentation by the provider, it was
very well outlined and recorded to show the clinical diagnosis of severe
pre-eclampsia. As per the ICD-10cm
guidelines, In coding for obstetrics, if the trimesters are known, it is to be
coded, in addition to the weeks of gestation.
When coding for this scenario in CPT, the E&M of the
emergency room physician is considered “separately identifiable” from the
obstetricians’ charges. Therefore, it is
appropriate to code and bill for the emergency room physician, based upon the
documentation.
When choosing the CPT code for the delivery, the coder
will need to ascertain whether or not the delivery was performed as a “global”
service. If the global service was
performed by the OB provider, the entire spectrum of pregnancy care (which
includes; antepartum, delivery care, and postpartum care services) should be
billed. If the physician performed only
the cesarean delivery and is not the global provider of service, then the cesarean
only code should be billed. This also
holds true if the provider performed the cesarean and is going to provide the
postpartum care too.
ICD-10pcs – the coder needs to know whether or not the
cesarean was performed as a classical, low cervical, or extraperitoneal
cesarean section. In the operative note,
the physician noted this was a low transverse cesarean section. The ICD-10 tables bring us to the code 10D00Z1
Extraction, Products of Conception, Low Cervical cesarean section.
If you are not seeing all the information you need in the
clinical documentation to determine if the diagnosis is “hypertension” “pre-eclampsia” “Eclampsia” or “HELLP” syndrome, do not hesitate to query the provider and ask
for additional clarification to be documented in the record.
Lori-Lynne
A. Webb, CPC, CCS-P, CCP, CHDA, 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 webbservices.lori@gmail.com or you can also find current
coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.
