Coding corner update: Use these coding tips to improve medical record documentation for pregnancy

Beginning Oct. 1, 2015, the transition to ICD-10-CM will affect every area of health care. Many codes contain much greater specificity. In the next several issues of The Record, you’ll find a series of revised “Coding corner” articles that include updated codes to align with the transition to ICD-10-CM.

Documentation and coding for pregnancy complications is a challenge for many coders and providers. With ICD-10, the reporting of pregnancy, childbirth and the puerperium have undergone significant changes. Understanding some of the changes and the official ICD-10-CM guidelines can simplify this complicated topic.

Coding tips
A complication 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 a Z to indicate if the patient is in her first pregnancy or if she’s been pregnant more than once:

These codes are not to be used in conjunction with chapter 15 codes for complications of pregnancy, childbirth and the puerperium.

If the encounter is for a condition unrelated to the pregnancy, assign the condition code first, along with code Z33.1, pregnant state, incidental. It’s the provider’s responsibility to state that the condition being treated is not affecting the pregnancy.

Report a code(s) from category O09 for prenatal outpatient visits for supervision of patients with high-risk pregnancies as the first listed diagnosis. Secondary chapter 15 codes may be used in conjunction with these codes if appropriate.

ICD-10-CM guidelines state that obstetric codes O00-O9A have sequencing priority over codes from other chapters.

Ectopic and molar pregnancies (O00-O02.9)
Report a code from category O01for non-cancerous types of Hydatidiform mole. For a molar pregnancy use code O02.0. 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). These pregnancies are not viable except in rare instance and are also very dangerous to the mother due to the risk of internal bleeding. Report a code from O00 category for an ectopic pregnancy. The fourth character indicates the extrauterine location of the ectopic pregnancy. Report complications following an ectopic or molar pregnancy with codes from category O08. If maternal care is provided for a viable fetus in abdominal pregnancy, report a code from category O36.7.

Other pregnancy with an abortive outcome (O03-O08)
This category includes spontaneous abortion, complications following (induced) termination of pregnancy, failed attempted termination of pregnancy, and complications following ectopic and molar pregnancy. ICD-10-CM contains separate codes for each of the types of complications which could occur for spontaneous, induced or attempted termination of pregnancy as well as complications following ectopic or molar pregnancy. An important change to note is that ICD-10-CM no longer uses the terms legally induced or illegally induced abortion.

• Report O03.9 for complete or unspecified spontaneous abortion, including miscarriage without complications. Spontaneous abortions occur naturally at less than 20 weeks gestation. It is important to note that the time frame for abortion versus fetal death changed from 22 weeks in ICD-9-CM to 20 weeks in ICD-10-CM.

Obstetric code trimesters
Coding of pregnancy in ICD-10 changed from the episode of care (indicating whether a condition was antepartum or postpartum or whether a delivery occurred) to identifying which trimester the complication occurred. Trimesters are defined as follows:

• First Trimester (less than 14 weeks 0 days)
• Second Trimester (14 weeks 0 days to less than 28 weeks 0 days)
• Third Trimester (28 weeks 0 days to delivery)
• Unspecified Trimester

Assignment of the final character for trimester should be based on the provider’s documentation of the trimester or number of weeks for the current admission/encounter.

• An additional code from Z3A to be used to identify the specific weeks of gestation

When coding complications specific to multiple gestation, report the 7th characters assigned to specifically identify the fetus for which the code applies. A place holder of X must be reported as the 6th character to make it a valid code. Please refer to the coding rules for these codes, example code category O64.

Current conditions complicating pregnancy
For patients with a current condition that affects management of the pregnancy, childbirth or puerperium, assign a code from Chapter 15 first. A secondary code is required from other chapters to further specify the current conditions.

For example, a pregnant woman at 23 weeks gestation who has a diagnosis of hypothyroidism would be coded with:

• O99.282 Endocrine, nutritional and metabolic diseases complicating pregnancy, second trimester
• E03.9 Hypothyroidism, unspecified
• Z3A.23 Weeks of gestation of pregnancy, 23 weeks

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 pregnant woman at 12 weeks gestation diagnosed with uncomplicated Type 2 diabetes before becoming pregnant should be assigned code O24.111 (Pre-existing diabetes mellitus, type 2, in pregnancy, first trimester), in addition to a second code from category E11.9 (Type 2 diabetes mellitus without complications). Also code the weeks of gestation, which in this case is Z3A.12 (12 weeks of gestation of pregnancy).

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 using category O24.4, gestational diabetes mellitus.

Report Z79.4, long-term, current use of insulin if the diabetes is being treated with insulin. It’s important to remember pre-existing and gestational diabetes should not be reported on the same record.

Hypertension in pregnancy, childbirth and the puerperium
Hypertension is the most common complication during pregnancy. Hypertension complicating pregnancy, childbirth and the puerperium should be assigned a code from the categories listed below:

Pre-eclampsia
Pre-eclampsia is a condition that starts after the 20th week of pregnancy. Pre-eclampsia 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. The only way to resolve pre-eclampsia is to deliver the baby.

Pre-eclampsia is classified to the following categories

• O14.0 — Mild to moderate pre-eclampsia (is when a pregnant woman develops high blood pressure and protein in the urine late in the second or third trimester).
• O14.1 — Severe pre-eclampsia (requires the basic features of mild pre-eclampsia as well as some indication of additional problem with either the mother or baby).
• O11.1 to O11.9 — Pre-existing hypertension with pre-eclampsia (Pre-eclampsia 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.)

Eclampsia is coded to category O15 - Eclampsia, and if the hypertension is unspecified then category O16 - unspecified maternal hypertension is used.

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 using the O44.0 category of codes (without hemorrhage) and O44.1 category of codes (with hemorrhage).

Oligohydramnios
Report codes from category O41 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. You must report the 6th character of X and the 7th character appropriate for the specific fetus.

It’s important to review the official ICD-10-CM guidelines for Chapter 15, as well as any instructional notes under the codes in the tabular list of the ICD-10-CM manual, to ensure correct code selection and sequencing.

ICD-10-CM coding for all conditions should follow coding conventions, chapter specific guidelines and general coding guidelines.

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

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