By Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC
As we continue to learn and embrace ICD-10-CM, many coders are still feeling uncertain in their ability to code OB delivery and ancillary services as easily as we did using ICD-9-CM. In addition, ICD-10-CM has presented some new documentation challenges.
I recently presented a webcast about how to unbundle the pregnancy package and use the coding concepts available in ICD-10-CM. I got some great questions, but simply didn’t have enough time to get to all of them during the presentation. I think a lot of coders are probably asking similar questions, so I’ve answered them below. I will follow up with additional questions and answers in a future column.
Q: During the delivery, if the physician documents group B strep (GBS) positive on the delivery note, do you code O99.824 (streptococcus B carrier state complicating childbirth) and Z3A.- (weeks of gestation)?
A: Yes, this is proper coding for the GBS notation, however the provider also needs to document 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 noted 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 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.
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.
Q: Do we have to put the ICD-10-CM Z3A.- weeks of gestation codes on every single encounter for OB patients?
A: According to the American Health Information Management Association, the Z3A.- weeks of gestation codes 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 her first-trimester ultrasound at 11 weeks, just by reviewing the claim and/or patient data.
Q: What code are you using when there is a current condition that the mother has, e.g., rheumatoid arthritis?
A: 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 coexisting medical diagnosis.
In the case you mention, where the mother has rheumatoid arthritis but it is not specifically noted as a complication, and the patient has a non-complicated birth, the codes below could be considered:
- O80, encounter for full-term uncomplicated delivery
- M06.9, rheumatoid arthritis, unspecified
- Z37.-, birth status
- Z3A.-
However, if the provider is documenting that the mother’s rheumatoid arthritis is currently complicating the pregnancy and/or delivery, then the following ICD-10-CM codes could be considered based upon the provider’s actual documentation or information after a query:
- O26.89-, other specified pregnancy-related conditions
- M06.9, unless you have more specificity regarding the rheumatoid arthritis
- Z37.-
- Z3A.-
According to the ICD-10-CM Official Guidelines for Coding and Reporting:
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.
Q: If patient is admitted to the hospital for a complication in the second trimester, how do we indicate this is not a delivery? When the patient delivers, we want to ensure we are not denied for it being already paid as part of the global package.
A: When you are billing for your complication in the second or third trimesters and the patient is still pregnant (undelivered), the appended ICD-10-CM codes 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-CM coding guidelines.
The guidelines state:
- 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.
Codes in this category are:
· 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
o Z37.50, multiple births, unspecified, all liveborn
o Z37.51, triplets, all liveborn
o Z37.52, quadruplets, all liveborn
o Z37.53, quintuplets, all liveborn
o Z37.54, sextuplets, all liveborn
o Z37.59, other multiple births, all liveborn
· Z37.6-, other multiple births, some liveborn
o Z37.60, multiple births, unspecified, some liveborn
o Z37.61, triplets, some liveborn
o Z37.62, quadruplets, some liveborn
o Z37.63, quintuplets, some liveborn
o Z37.64, sextuplets, some liveborn
o Z37.69, other multiple births, some liveborn
· Z37.7, other multiple births, all stillborn
· Z37.9, outcome of delivery, unspecified
Q: In ICD-10-CM, can you bill codes O35.5- (maternal care for [suspected] damage to fetus by drugs) and O99.33- (smoking [tobacco] complicating pregnancy, childbirth, and the puerperium) at the same encounter? What about code O99.32- (drug use complicating pregnancy, childbirth, and the puerperium)?
A: In ICD-10-CM, as with all coding, pay close attention to what the code is actually stating and look at the key verbiage within the code set.
Code O35.5- denotes that the provider is concerned with care provided to the mom, due to “suspected” damage to the fetus from drugs (e.g., 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).
Code O99.33- is for use when the provider specifically notes that the mother’s use of tobacco is complicating her pregnancy care and oversight. Code O99.32- is for use when drug usage by the mother (this can be any type of drug, e.g., prescription necessitated, over the counter, herbal, legal, illegal) is complicatingthe pregnancy care.
All three of these codes can be coded together, however, when coding O35.5- the provider is required to document the suspicion that there may be damage to the fetus from the usage of a particular drug (e.g., the patient is pregnant and currently prescribed drugs for a seizure disorder that may be harmful to a fetus).
Q: When twins are born via cesarean on different dates (e.g., past midnight), how do I report this?
A: In this instance, the cesarean procedure date and time will be noted on your claim, and with a twin cesarean, modifier -22 (increased procedural service) will be appended on the mother’s record. The coding would similar to this:
- CPT code 59514-22 (cesarean delivery only, with increased procedural service)
- ICD-10-CM code O82.0, encounter for cesarean delivery without indication
- ICD-10-CM code Z37.2
- ICD-10-CM code Z3A.-
However, if twin A is born at 11:58 p.m. and twin B is born at 12:02 a.m. (the next day) the twins’ 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 twin’s records, the date of service should correspond to the actual date of delivery.
Q: In regard to fetal non-stress tests (FNST), if the physician has not done an interpretation but two RNs have reviewed and documented it, can the hospital facility fee be charged?
A: The answer is yes. The rationale is the hospital owns the FNST equipment and all equipment and 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. For the RNs who reviewed the test, their responsibility lies in getting the service for the usage of the equipment posted in the chargemaster so it will be billed.
Q: Would you code Category ll or Category lll fetal heart tones if mentioned in the delivery chart? What needs to be documented to show this affects the management of the mother?
A: In regard to the actual ICD-10-CM coding for Category II or Category III fetal heart tracing, it depends on what the provider has actually documented. The ICD-10-CM codes do not correspond to the terms “Category II” or “Category III.” ICD-10-CM 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 provider’s responsibility to provide appropriate documentation of the FNST and he or she needs to include the medical necessity for the testing (i.e., diagnosis). The clinical documentation from the provider must also support the findings if the testing is noted as Category I, II, or III and how management of the patient is impacted due to the findings within the test.
According to the National Institute of Child Health and Human Development workshop report on electronic fetal monitoring, a Category I tracing is characterized by a FNST or fetal heart rate (FHR) during labor (continuous or intermittent) with:
- A 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. For Category II tracings:
- 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 aclearly 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 per minute that persists for 20 minutes or longer is also classified as a Category III tracing.
Editor’s note: Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, AHIMA-approved ICD-10-CM/PCS trainer, is an E/M and procedure-based coding, compliance, data charge entry, and HIPAA privacy specialist, with more than 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 email at [email protected] or find current coding information on her blog: http://lori-lynnescodingcoachblog.blogspot.com. For more information, see the HCPro webcast Unbundle the Pregnancy Package and Manage ICD-10 Changes.