OB Coding: Delivering Accurate Coding Remains a Challenge

To quote Robert F. Kennedy, “There are those that look at things the way they are, and ask ‘why?’ I dream of things that never were, and ask ‘why not?’”

Coders are experts at scanning provider documentation and assigning codes. My approach to chart review is to try to piece together what actually happened during the encounter, and then evaluate whether the documentation supports the coding of the story. This two-part series of articles will address encounters that result in the delivery of a newborn, as opposed to situations like prenatal encounters or caring for the ectopic pregnancy. Today I tackle the procedure side, and next week I will expand on the diagnosis side.

Obstetrics coding is particularly challenging. I always say that documentation is for clinical communication, but if you have ever read an obstetrics encounter, you really are struck with the fact that obstetricians and nurse midwives are documenting solely to communicate with each other. I practiced emergency medicine for 25 years, and their alphabet soup had me constantly checking the medical dictionary of abbreviations until I could decipher their codes.

Another hurdle is that for most coding, we live in the Medicare-Severity Diagnosis Related Group (MS-DRG) world, but obstetrics coding is often All-Patient-Refined DRG (APR-DRG)-based because this is not a Medicare-age or covered patient population. There is not a direct crosswalk between MS-DRGs and APR-DRGs. Nor is there a direct correlation between comorbid conditions and complications (CCs) or major comorbid conditions and complications (MCCs) and conditions that risk-adjust the severity-of-illness (SOI) level. The base APR-DRG is subdivided into four tiered subcategories based on the SOI score, and the reimbursement is based on the corresponding APR relative weight.

OB coding is predicated on two main issues: getting the correct principal diagnosis (PD) and accurately codifying the procedure(s). Also, since ICD-10 did away with “delivered, with or without mention of antepartum complication,” there is no implied delivery in the ICD-10-CM code, so it is very important to indicate that a delivery was performed or you might end up in the wrong DRG. This is accomplished by a “delivery” code (quotation marks to distinguish the medical procedure from the root operation here) and an outcome of delivery code.

I group these procedures into three general categories:

1. Prior to delivery: There are procedures that may bring on or hasten labor, or facilitate a vaginal delivery. Labor is defined as uterine contractions resulting in cervical dilation and/or effacement. Augmentation of labor is the stimulation of the strength or frequency of uterine contractions using pharmacologic methods or artificial rupture of membranes (AROM) after spontaneous labor or spontaneous rupture of membranes (SROM) has occurred. Induction of labor (IOL) is the use of pharmacologic and/or mechanical methods to initiate labor, including the circumstance of SROM without contractions. Also, consider the following:

• Procedures for augmentation of labor are not coded, except for AROM.
• Administration of oxytocin/Pitocin for IOL is coded as 3E033VJ, Introduction of other hormone into peripheral vein, percutaneous approach.
• Cervical ripening is the softening of the cervix to allow for effacement and dilation, and it is accomplished with cervical inserts that often release prostaglandins (e.g., dinoprostone, misoprostol, mifeprex). The code used is 3E0P7GC, Introduction of other therapeutic substance into female reproductive, via natural or artificial opening.
• Cervical dilation is accomplished by mechanical means such as a balloon or digital exam, and it is coded as 0U7C7ZZ, Dilation of cervix via natural or artificial opening. This presupposes that the dilation is temporary and no device is left in place.
• AROM is coded as 10907ZC, Drainage of amniotic fluid, therapeutic, from products of conception via natural or artificial opening.
• Version is the manipulation of the fetus to improve the odds of a vaginal delivery in the case of an unfavorable presentation. If it is done entirely on the abdomen, the approach is external, 10S0XZZ, Reposition products of conception, external approach; if internal version is performed, 10S07ZZ, Reposition products of conception via natural or artificial opening.
• Fetal monitoring is comprised of external and internal modalities. The external, performed on the mother’s abdomen, is monitoring the products of conception. It is found in the Measurement and Monitoring section of PCS and the code is 4A1HXCZ. Internal monitoring requires two codes: one for the insertion of the monitoring electrode onto the fetus’s scalp via natural or artificial opening (10H73Z), and one for the monitoring, which is the same as above except for the approach, which is again via natural or artificial opening (4A1H7CZ).

2. The delivery method:

• 10E0XZZ, Delivery of products of conception, external approach is reserved for manually assisted vaginal delivery without any instrumentation to assist in removal of the fetus.
• If a vaginal delivery is performed with instrumentation, the procedure is considered an extraction (pulling or stripping out or off all or a portion of a body part by the use of force). The codes are in the 10D07Z_ set, with the final character specifying low forceps, mid forceps, high forceps, vacuum, internal version, or other.
• The Cesarean section (Csxn) is considered an extraction as well. The most commonly performed version is 10D00Z1, Extraction of products of conception, low cervical, open approach.
• If vaginal delivery fails, you only code the Csxn. Unless they add a qualifier of vacuum extraction to Csxn, vacuum-assisted Csxn is only coded as the specific extraction, open approach.

3. Procedures performed in conjunction with the delivery or as a result of a complication of the delivery can include:

• Sterilization, which can be accomplished with the root operations of destruction, excision, occlusion, or resection.
• Dilation and curettage, which is extraction of retained products of conception or endometrium.
• An intentionally performed release to permit egress of the fetus is called an episiotomy, and it is a division of the female perineum, external approach, code 0W8NXZZ. The repair of the tissues is implied, similar to not coding the closure of a skin incision.
• Repair of traumatic damage, such as a perineal tear.

Determining what was torn and repaired during a delivery sometimes requires a query. If your institution templates the documentation of the delivery, you may be able to facilitate capturing the detail so you can accurately report the ICD-10-PCS codes.

Capturing all the relevant procedures may determine whether a patient is categorized in a “surgical” or “medical” DRG, if MS-DRG is the methodology. The crux of OB coding, however, lies in the selection of the appropriate PD and the recognition of additional conditions to be codable diagnoses. As is typical, the provider not documenting diagnoses with the correct verbiage often prevents the telling of the whole story.

Next week, I will look at the peculiarities of obstetric ICD-10-CM coding and how to select diagnoses that do tell the whole OB story.