April 13, 2009

Review of Pregnancy Coding Guidelines
For The Record
Vol. 21 No. 8 P. 31

When a pregnant patient is admitted, codes from ICD-9-CM chapter 11 (code range 630 to 679) are required. The pregnancy-related codes take sequencing priority over codes from all other ICD-9-CM chapters, meaning pregnancy codes will be sequenced as the principal diagnosis, since it’s assumed the condition necessitating the admission was affecting or was affected by the pregnancy. If the condition being treated doesn’t affect or isn’t affected by the pregnancy, the physician must specifically document this information in the medical record. Code V22.2 will be assigned in place of any chapter 11 codes if the physician documented that the pregnancy is incidental to the admission. 

Although the pregnancy-related code must be sequenced first, additional codes from other chapters may be assigned as secondary diagnoses to completely classify the condition. Also, chapter 11 codes are only assigned on the pregnancy record and should never be assigned on the newborn record. 

Selection of the principal diagnosis depends on the main reason or complication of the encounter. If a patient is admitted but does not deliver during this episode of care, the principal diagnosis will depend on the circumstances of admission. If there is more than one pregnancy complication and all are treated, evaluated, or monitored, then any of the pregnancy complication codes may be sequenced first. If the patient does deliver during this episode of care, then the main circumstance should be sequenced first. If the patient undergoes a Caesarean section, then the reason necessitating the C-section should be sequenced as the principal diagnosis. Assign code 669.71 as the principal diagnosis if a C-section is performed with no mention of indication documented. It would not be appropriate to assign code 650 as the principal diagnosis when a C-section is performed (AHA Coding Clinic for ICD-9-CM, 2001, first quarter, pages 11-12).

If a patient is admitted for a complication of pregnancy and during the hospital stay, a C-section is performed for other reasons, the principal diagnosis will be the condition that necessitated the admission, not the reason for the C-section.

Codes from category 655 or 656 should be assigned if the presence of a fetal condition affects or modifies the mother’s management. If the fetal condition doesn’t require diagnostic studies, additional observation, or other special care, then a code from one of these two categories shouldn’t be assigned.

If a pregnant patient has an HIV-related illness or AIDS, code 647.6x is assigned as the principal diagnosis, followed by code 042 and the code for the HIV-related illness. If the pregnant patient is HIV positive or has asymptomatic HIV infection, assign codes 647.6x and V08 in that sequence.

Assign a code from category 648 for patients who have a current condition affecting pregnancy. Diabetes mellitus in pregnancy is classified to code 648.0x and gestational diabetes to code 648.8x. Code V58.67 should also be assigned as a secondary diagnosis if the patient is being treated with insulin. Codes 648.0x and 648.8x should never be used together on the same record.

To assign code 650, Normal delivery, the patient must meet these requirements: a full-term pregnancy; a single, liveborn infant; no unresolved antepartum, during the delivery, or postpartum complications; no instrument-assisted delivery except episiotomy (73.6), amniotomy (artificial rupture of the membranes), or fetal monitoring (75.34); cephalic presentation; and no fetal manipulation.

If a patient is admitted for labor induction without an indication or a reason and no complications occur during the delivery, code 650 may be assigned as the principal diagnosis. Code 73.01 may be assigned for the induction. The assignment of this procedure code will not conflict with the use of code 650 because it does not indicate a complicated pregnancy or delivery (AHA Coding Clinic for ICD-9-CM, 2000, third quarter, page 5).

If a patient is admitted within six weeks after delivery, assign the postpartum complication code as the principal diagnosis. If, however, the physician specifically documents that it’s not a postpartum complication, the condition will be coded as normal without a pregnancy-related code.

If the physician documents that the patient has a postpartum condition, even after the six-week time frame, the condition should be coded as postpartum. For example, if a patient is admitted nine weeks postpartum with cardiomyopathy and the physician documents postpartum cardiomyopathy, code 674.54 should be assigned as the principal diagnosis.

For a complete review of the guidelines, refer to AHA Coding Clinic for ICD-9-CM, 2008, fourth quarter, pages 245-252.

Coding and sequencing are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 4,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.