Ask the Expert

This month’s selection:

I work as a coder in an OB/GYN hospital. I came across a case where the patient had suffered a spinal cord injury one year previously and recently underwent a cesarean delivery. The indication for cesarean delivery was given as previous spinal cord injury. Please tell me what ICD-9-CM diagnosis code to assign for this case.

Shazia Maddi
Al Corniche Hospital
Abu Dhabi, United Arab Emirates

 

Response:
I’d use 648.91, Current condition in mother, complicating pregnancy, delivered. “Other problem in mother, not specifically related to the pregnancy or labor or delivery, that began prior to the delivery but is nonetheless complicating this episode of care, and she delivered on this encounter.” (That’s the long version—it’s what the code means.)

— Judy Sturgeon, CCS, CCDS, is the clinical coding/reimbursement compliance manager at Harris County Hospital District in Houston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and compliance for 21 years.

 

Follow-up question:
Does an add-on code need to be included along with 648.91? If so, then what should be the other ICD code? Or can we code 669.71, Cesarean delivery without mention of indication?

— SM

Follow-up response:
Actually, no, there isn’t a need for an add-on code. To have an additional diagnosis, there has to be a diagnosis. In this case, it sounds like they are doing a C-section as a cautionary measure due to a history of a spinal cord injury. I wouldn’t use 669.71 because there is an indication, just not a current diagnosis. V15.59, Personal history of injury, seems appropriate, just not very informative. But if you want to provide some detail along with 648.91, the V code would serve that purpose.

— JS