Keep these coding tips in mind to improve medical record documentation

This is part of a series of articles on coding tips that has been running in The Record since May 2013. This month, we’re focusing on coding for pregnancy complications.

Documentation and coding complications for pregnancy is a challenge for many coders and providers. Understanding some of the definitions and the official ICD-9 CM guidelines can simplify this complicated topic.

Complications in pregnancy may range from the mother smoking during the pregnancy to the worst-case scenario, death.

Routine outpatient prenatal visits with no complications should be coded with an ICD-9-CM V Code to indicate if the patient is in her first pregnancy or if she’s been pregnant more than once:

• V22.0: Supervision of normal first pregnancy
• V22.1: Supervision of other normal pregnancy

These codes are not to be used in conjunction with Chapter 11 codes for complications of pregnancy, childbirth and the puerperium.

If the encounter is for a condition totally unrelated to the pregnancy, assign the condition code first, along with code V22.2, Pregnant state, incidental. The code is a secondary code only for use when the pregnancy is in no way complicating the reason for the visit. Otherwise, a code from the obstetric chapter is required. It’s the provider’s responsibility to state that the condition being treated is not affecting the pregnancy.

For example, if a pregnant woman visits a health care provider to receive a cast for a fractured arm, then the pregnancy is considered incidental.

Report a code from category V23.X for routine prenatal outpatient visits for patients with high-risk pregnancies. Secondary chapter 11 codes may be used in conjunction with these codes if appropriate.

ICD-9-CM guidelines state that obstetric codes 630–679 take precedence over all other codes.

Ectopic and molar pregnancies (630-633)
Report code 630, hydaridiform mole, for a molar pregnancy. Molar pregnancies occur when tissue that normally becomes a fetus develops into an abnormal mass of cysts. The embryo is unformed or malformed and cannot survive.

Ectopic pregnancy means “out of place” or occurring outside the womb (uterus). It’s life-threatening to the mother. A fourth digit indicates the extrauterine location of the ectopic pregnancy. The fifth digit "0" indicates there is no intrauterine pregnancy in addition to the ectopic pregnancy. A fifth digit of "1" indicates there’s an intrauterine pregnancy in addition to the ectopic pregnancy.

• 633.00 and 633.01 Abdominal pregnancy
• 633.00 and 633.10 Tubal pregnancy
• 633.20 and 633.21 Ovarian pregnancy
• 633.80 and 633.81 Other ectopic pregnancy

Other pregnancy with an abortive outcome (634-639)
This category includes spontaneous abortion, legally-induced abortion, illegally-induced abortions, unspecified abortion and failed attempted abortion. An informational box is provided for categories 634-638 in the ICD-9-CM that identifies subterms for various complications by division. An informational box is also provided that indicates fifth-digit stages for abortion unspecified (0), incomplete (1) and complete (2):

• Report 634.XX for spontaneous abortion, including miscarriage. Spontaneous abortions occur naturally at less than 22 weeks gestation.

Pregnancy categories 640-648 and 651-676 require a fifth-digit code to indicate whether the episode is antepartum or postpartum, and if a delivery has occurred. For the purpose of this article, we’re focusing on antepartum conditions with the fifth digit 3:

• Antepartum — Occurring during pregnancy before childbirth, with reference to the mother
• Postpartum — Immediately after delivery and continues six weeks following delivery, with reference to the mother.

The fifth digits are listed in brackets under each code heading to denote the current episode of care:

• 0 — Unspecified as to episode
• 1 — Delivered with or without antepartum condition
• 2 — Delivered with postpartum condition
• 3 — Antepartum condition or complication
• 4 — Postpartum condition or complication

When coding multiple pregnancy complications, all fifth digits should be consistent with each other.

Current conditions complicating pregnancy
For patients with a current condition that affects management of the pregnancy, childbirth or puerperium, assign a code from subcategory 648.XX. An additional secondary code is required from other chapters to identify the current conditions.

For example, a pregnant woman who has a diagnosis of hypothyroidism would be coded with:

• 648.1X Thyroid dysfunction
• 244.9X Unspecified hypothyroidism

Diabetes in pregnancy
Diabetes is a significant complication in pregnancy. Before coding, you must first determine if the condition is gestational or predates the pregnancy.

For example, a woman diagnosed with Type 2 diabetes before becoming pregnant should be assigned code 648.03 (diabetes mellitus complicating pregnancy), in addition to a second code from category 250.XX (primary diabetes mellitus) to identify the type of diabetes.

A woman not diabetic prior to pregnancy may develop gestational diabetes during the second and third trimesters. Gestational diabetes may cause complications similar to those of a woman with pre-existing diabetes mellitus. Gestational diabetes is coded 648.83, abnormal glucose tolerance.

Report V58.67 (long-term, current) if either condition is being treated with insulin. It’s important to remember codes 648.0X and 648.8X should never be used together on the same record.

Hypertension in pregnancy
Hypertension is the most common complication during pregnancy. Hypertension complicating pregnancy should be assigned a code from 642.X3:

• 642.03 — Benign essential hypertension
• 642.13 — Hypertension secondary to renal disease
• 642.23 — Other pre-existing hypertension
• 642.33 — Transient hypertension of pregnancy
• 642.93 — Unspecified hypertension

Preeclampsia is a condition that starts after the 20th week of pregnancy. Preeclampsia is related to increased blood pressure and protein in the mother’s urine. The condition affects the placenta and it can threaten the lives of both the mother and baby.

• 642.4 — Mild or unspecified preeclampsia is when a pregnant woman develops high blood pressure and protein in the urine late in the second or third trimester.
• 642.5 — Severe preeclampsia requires the basic features of mild preeclampsia as well as some indication of an additional problem with either the mother or baby.
• 642.6 — Eclampsia follows the condition preeclampsia and causes seizures in a pregnant woman.
• 642.7 — Preeclampsia or eclampsia superimposed on pre-existing hypertension presents in a patient with chronic hypertensive vascular or renal disease. When hypertension precedes the pregnancy as established by previous blood pressure recordings. A rise in systolic pressure of 30mmHg or a rise in diastolic pressure of 15mmHg and the development of proteinuria and edema are required during pregnancy to establish this diagnosis.

The only way to resolve preeclampsia is to deliver the baby.

Placenta previa
Placenta previa is when the placenta is lying unusually low in the uterus. This condition usually occurs around 27 to 32 weeks of gestation. In a case of partial placenta previa, it may resolve on its own; however, if the placenta covers the cervix completely, it’s called complete or total previa. If present at time of delivery, a cesarean section will need to be performed. Placenta previa is coded as 641.03 (without hemorrhage) and 641.13 (with hemorrhage).

Oligohydramnios
Report 658.XX for oligohydramnios. This is a complication when there’s not enough amniotic fluid. If oligohydramnios happens in the first two trimesters of pregnancy, it’s more likely to cause serious problems than if it occurs in the last trimester.

It’s important to review the official ICD-9-CM guidelines for Chapter 11, as well as any instructional notes under the codes in the tabular list of the ICD-9-CM manual, to ensure correct code selection and sequencing.

If you have questions or need more information, contact your provider consultant.

None of the information included in this article is intended to impart legal advice and, as such, it remains the provider’s responsibility to ensure that coding and documentation are done in accordance with all applicable state and federal laws and regulations.