Obstetric Coding Quality Error Trends

Presentation Date: 6/14/2022

 Objective
This education presentation is being provided to assist the coder in correct
coding based on current OB error trends

Outline
Key Error Trends
ICD-10-CM/PCS Coding Handbook
AHA Coding Clinic Guidance

Parallon Audit Review Diagnoses

Includes Coding Conventions and associated coding guidance

References
 Key Error Trends
➢ Missed Query Opportunities (pathology, DM type/acuity, HTN type/acuity,
complications)

➢ Misunderstanding of the different type of inductions, medical vs

instrumental

➢ Complications (chorioamnionitis, atony, inertia, etc.)

➢ Correct Date of Admit (used to determine the weeks of gestation when

admits encompass more than one gestational week)

➢ Correct POA assignment (abnormal fetal heart rate, uterine inertia,

anemia)

➢ COVID coding (requires lab results noted in the LAB section of CAC for
reporting)
 Missed Query Opportunities
As with any encounter we code, it is imperative that we not only code what
has been documented; but also, to utilize our critical thinking skills in order
to recognize when there is a need for query for additional diagnoses that are
supported by the documentation in the medical record.

Missed Query Opportunity Examples:

Pathology: Whenever there are abnormal pathology results in the medical

record, a query is in order. We must use those results with the other
abnormal findings and clinically supporting documentation to create our
query. Example: If chorioamnionitis is noted on the pathology results, we
need to look for supporting documentation such as fever or other
examination support for the condition to use as Clinical Indicators (along
with the pathology findings). We should also include any physician
documentation of the “need” or “reason” for sending the placenta for
pathology.
 Missed Query Opportunities
Missed Query Opportunity Examples (cont.):

Diabetes Mellitus: When a patient is documented as having diabetes, but

there is no documentation of whether the condition existed prior to
pregnancy, a query is required. It is very important to code the condition to
the highest specificity available and to distinguish between preexisting
diabetes and gestational diabetes.
Example: When the physician documentation states only diabetes or
DM and there is no specificity whether the diabetes is preexisting or
gestational, a query is required.

Hypertension: When a patient is documented has having hypertension, but

there is no documentation of whether the condition existed prior to
pregnancy, a query is required.
Example: When the physician documentation states simply
hypertension in the absence of type/acuity specificity, a query needs to be
sent for clarification of whether the patient’s hypertension is preexisting or
gestational.
 Types of Induction
Induction procedures should always be reported when performed. The Fourth
Characters distinguish between medical, instrumental, and other or unspecified
methods of induction of labor.

Medical Induction includes administration of Pitocin/Oxytocin and etc..

Instrumental Induction includes surgical induction such as Foley catheter

balloon induction and etc..

Common Types of Induction…

• Amniotomy (AROM)
• Amnioinfusion
• Cervical dilation
• Introduction of Therapeutic Substance
• Pitocin/Oxytocin administration (specifically documented as “to induce labor” –
cannot be reported if patient is already in labor on admission)
• Prostaglandins (gel or suppositories) are sometimes used to ripen and soften
the cervix
• Sweeping the membranes of the amniotic sac to help induce labor
 AHA Coding Clinic Guidance
AHA Coding Clinic 2nd Qtr 2020 – Duhrssen Cervical Incision

Question: A patient with twin pregnancy presented with Twin A in a frank breech
position too low in the vagina for a cesarean section. The decision was made for a
vaginal breech delivery. The head of Twin A was noted to be entrapped in the cervix
so a Duhrssen incision was performed to facilitate delivery. After Twin A was
delivered, Twin B experienced recurrent prolonged heart decelerations prompting
cesarean delivery of Twin B. After surgical closure of the cesarean section, the cervix
was examined and bleeding was noted from the Duhrssen incision, which was closed
with suture. What ICD-10-PCS code is assigned for a Duhrssen cervical incision and
is an additional code assigned for the repair?

Answer: The purpose of the Duhrssen incision is to widen the opening of the
incompletely dilated cervix to facilitate delivery of the trapped fetal head. Although
Division is the appropriate root operation, ICD-10-PCS table 0W8 does not provide a
body part value for Cervix. Therefore, the root operation Dilation is the closest
available option. Coding a Duhrssen incision is similar to coding an episiotomy. The
repair of the incision is integral to the procedure and not coded separately. Assign the
following ICD-10- PCS code:

0U7C7ZZ - Dilation of cervix, via natural or artificial opening, for the Duhrssen
incision
 AHA Coding Clinic Guidance
AHA Coding Clinic 2nd Qtr 2014 - Medical Induction of labor with
Cervidil Tampon Insertion

Question: A pregnant patient underwent medical induction of labor with

Cervidil Dinoprostone vaginal tampon. The patient had spontaneous vaginal
delivery at 37 weeks. What is the correct ICD-10-PCS code for medical
induction of labor with Cervidil Dinoprostone vaginal tampon insert?

Answer: Cervidil (Dinoprostone/prostaglandin gel insert) is used to ripen

and soften the cervix, causing uterine contractions. Assign ICD-10-PCS
code as follows:

3E0P7GC – Introduction of Other Therapeutic Substance into

Female Reproductive, Via Natural or Artificial Opening
 AHA Coding Clinic Guidance
AHA Coding Clinic 2nd Qtr 2014 – Pitocin Administration to Augment Labor

Question: A pregnant patient presents to the hospital at 40 weeks gestation in active labor.
Artificial rupture of the fetal membranes (AROM) is carried out and Pitocin is given
intravenously in the peripheral vein to augment labor. The patient had a spontaneous vaginal
delivery of a live born infant without complication. Is the administration of Pitocin to augment
active labor coded separately in ICD-10- PCS? How should this case be coded?

Answer: Assign code O80, Encounter for full-term uncomplicated delivery, as the principal
diagnosis. Codes Z3A.40, 40 weeks of gestation of pregnancy, and Z37.0, Single live born,
should be assigned to describe weeks of gestation and the outcome of the delivery.

The administration of Pitocin to augment active labor is not coded separately. In this case, the
patient presented in active labor; therefore, do no assign a separate code for the
administration of Pitocin. When Pitocin is given to induce labor, it should be coded. For the
assisted delivery and artificial rupture of the membranes, assign ICD-10- PCS procedure
codes as follows:

10E0XZZ - Delivery of products of conception, external approach

10907ZC - Drainage of amniotic fluid, therapeutic from products of conception, via

natural or artificial opening
 AHA Coding Clinic Guidance
AHA Coding Clinic 1st Qtr 2022 – Spontaneous Abortion with Retained
Placenta of Twin B

Question: A patient arrived at the Emergency Department (ED) with vaginal bleeding at 18
to 19 weeks gestation and had a spontaneous vaginal delivery of twin A, in the ED. Upon
the initial assessment in Labor and Delivery, twin B had heart tones, but expulsed
spontaneously within the next few minutes. The placenta of twin A was removed intact
without complication. The placenta of twin B was difficult to extract manually and remained
in utero. Due to postpartum hemorrhage and retained placenta, a suction curettage was
performed with removal of the remaining placenta. What are the diagnosis and procedure
code assignments for this case?

Answer: Assign codes O03.6, Delayed or excessive hemorrhage following complete or

unspecified spontaneous abortion, for spontaneous delivery of twin A and O03.1, Delayed or
excessive hemorrhage following incomplete spontaneous abortion, for the incomplete
spontaneous abortion of twin B with retained placenta.

Assign the following ICD-10-PCS code:

10D17ZZ - Extraction of products of conception, retained, via natural or artificial

opening, for suction curettage removal of the retained placenta.

No delivery code is assigned for a spontaneous abortion.

 Complications
There are numerous labor complications, all complications should be reported on
the delivery encounter. The most common complications (not limited to) are
included below…

• Failure to progress (AKA prolonged labor)

• Uterine Inertia (weak or irregular uterine contractions during labor)
• Fetal distress (irregular heart rates, low amniotic fluid, issues with muscle tone and
movement)
• Chorioamnionitis (infection of the placenta and/or amniotic fluid)
• Shoulder dystocia (when the head of the infant delivers but the shoulder are still
within the mother)
• Uterine atony (failure of the uterus to contract following delivery)
• Excessive bleeding (vaginal deliveries over 500 mL, cesarean deliveries over 1000
mL)
• Malposition (infant facing up, frank breech with buttocks first or complete breech with
feet first)
• Placenta previa (the placenta covers the opening of the cervix)
• Cephalopelvic disproportion (infants head is too large to pass through the mother’s
pelvis)
• Rapid labor (when the 3 stages of labor only lasts 3-5 hours)
• Uterine rupture (caused by size of the infant, elderly multigravida, induction, previous
cesarean, and accidental injury due to instruments in vaginal delivery)
 AHA Coding Clinic Guidance

AHA Coding Clinic 2nd Qtr 2019 – Triple I (chorioamnionitis)

Question: The patient is a 29-year-old, who had a spontaneous vaginal

delivery. The provider's final diagnostic statement listed, "Triple I, premature
rupture of fetal membranes, and anemia." Our physicians have recently
started documenting a diagnosis of "Triple I" for obstetric patients during the
delivery episode with no further description. According to our research,
"Triple I involves intrauterine inflammation and/or infection, and is clinically
chorioamnionitis." Should we query the physician before assigning a code
from subcategory O41.12-, Chorioamnionitis? What is the appropriate code
assignment for "Triple I"?

Answer: Chorioamnionitis and Triple I are synonymous terms. Assign the

appropriate code from subcategory O41.12-, Chorioamnionitis, for Triple I.
 AHA Coding Clinic Guidance
AHA Coding Clinic 3rd Qtr 2018 – Delivery with Previous Cesarean Section
and Unspecified Type of Scar

Question: The provider documented "Successful vaginal birth after previous

cesarean delivery." Is it appropriate to assign code O34.219, Maternal care for
unspecified type scar from previous cesarean delivery?

Answer: When documentation states that the patient had a previous cesarean
section and the type of scar is not specified, assign code O34.219 - Maternal
care for unspecified type scar from previous cesarean delivery.

Coding Clinic, Fourth Quarter 2016, pages 51-52, clarified that subsequent
pregnancy and delivery management may be determined by the previous type
of cesarean incision. Patients with a previous cesarean scar are at an
increased risk for dehiscence and uterine rupture depending on the location of
the scar.
 AHA Coding Clinic Guidance
AHA Coding Clinic 3rd Qtr 2018 – Delivery with Previous Cesarean Section
and Unspecified Type of Scar

Question: A patient is admitted for repeat cesarean section. The postoperative

diagnosis on the procedure report states "Term pregnancy, previous low
transverse cesarean section." Is it appropriate to assign code O34.219,
Maternal care for unspecified type scar from previous cesarean delivery?

Answer: Assign code O34.211 - Maternal care for low transverse scar from
previous cesarean delivery, when a previous low transverse cesarean
section is documented.

As previously stated in Coding Clinic, "Subsequent pregnancy and delivery

management may be determined by the previous type of cesarean incision.
Patients with a previous cesarean scar are at an increased risk for dehiscence
and uterine rupture depending on the location of the scar."
 AHA Coding Clinic Guidance
AHA Coding Clinic 4th Qtr 2016 – Third Degree Perineal Laceration during
Delivery

Codes in subcategory O70.2, Third degree perineal laceration during delivery, have been
further expanded to subclassify third degree lacerations as grade IIIa, IIIb or IIIc
depending on the severity of the trauma.

The American Congress of Obstetricians and Gynecologists (ACOG), through its

collaborative hub, the Women's Health Registry Alliance (reVITALize), initiative worked
on the current classification of 3rd and 4th degree perineal lacerations to advance more
robust data collection by moving toward standardization with the Royal College of
Obstetricians and Gynaecologists.

The reVITALize definition for perineal lacerations is:

1° - Injury to perineal skin only
2° - Injury to perineum involving perineal muscles but not involving anal sphincter
3° - Injury to perineum involving anal sphincter complex
3a - Less than 50% of external anal sphincter (EAS) thickness torn
3b - More than 50% external anal sphincter (EAS) thickness torn
3c - Both external anal sphincter (EAS) and internal anal sphincter (IAS) torn
4° - Injury to perineum involving anal sphincter complex (external anal sphincter (EAS)
and internal anal sphincter (IAS) and anal epithelium
 AHA Coding Clinic Guidance
AHA Coding Clinic 4th Qtr 2016 – Third Degree Perineal Laceration during
Delivery (cont.)

The benefits for documenting subclassifications within coding include the ability
to risk stratify and/or adjust for measurement as well as the ability to identify
cases for chart review and quality improvement. The following are the new ICD-
10-CM codes for 3rd degree lacerations:

O70.20 - Third degree perineal laceration during delivery, unspecified

O70.21 - Third degree perineal laceration during delivery, IIIa

O70.22 - Third degree perineal laceration during delivery, IIIb

O70.23 - Third degree perineal laceration during delivery, IIIc

 AHA Coding Clinic Guidance
AHA Coding Clinic 4th Qtr 2016 – Placenta Previa
Category O44, Placenta previa, has been expanded and new codes created to differentiate
between low-lying placenta, partial, and complete placenta previa, and whether or not hemorrhage
is present. The default for "placenta previa NOS" and "low lying placenta NOS" is without
hemorrhage.

The new and revised subcategories are as follows:

O44.0 - Complete placenta previa NOS or without hemorrhage
O44.1 - Complete placenta previa with hemorrhage
O44.2 - Partial placenta previa without hemorrhage
O44.3 - Partial placenta previa with hemorrhage
O44.4 - Low lying placenta NOS or without hemorrhage
O44.5 - Low lying placenta with hemorrhage

Placenta previa is a condition that occurs when some portion of the placenta is covering the
internal cervical os. It may be either complete, where the internal cervical os is completely covered
by the placenta, or partial where the internal cervical os is partially covered by the placenta. Both
conditions may result in hemorrhage and require close monitoring. In many cases, cesarean
delivery is necessary. Clinically, complete placenta previa can complicate the pregnancy, cause
early delivery, and result in morbidity. Low lying placenta is a condition where the placenta
implants low in the uterus but does not cover the cervix. Although a low lying placenta can also
develop hemorrhage, the condition can be managed with conservative treatment, and is less likely
to result in early delivery. A partial placenta previa does not typically require extensive follow-up
and is more likely to resolve as the pregnancy progresses, prior to delivery.
 AHA Coding Clinic Guidance
AHA Coding Clinic 4th Qtr 2020 – Maternal Care for Other Type of Scar from Previous
Cesarean Section Delivery

Unique codes have been created to identify maternal care for other type of scar from previous
cesarean delivery (O34.218) and maternal care for cesarean scar (isthmocele) defect (O34.22).
These new codes describe non-lower uterine segment scars from previous cesarean delivery.

Women who have a prior non-lower uterine segment scar, such as a mid-transverse T incision
cesarean scar, are at higher risk of uterine rupture at the site of the previous uterine scar in
subsequent pregnancies. The surgeon may elect to perform a mid T incision when additional
space is required to deliver the infant. "Mid-transverse T incision" is an inclusion term under code
O34.218.

An isthmocele is a type of cesarean scar defect or niche that develops at the site of a previous
cesarean hysterotomy and is associated with an increased risk for uterine rupture. Other
complications may include but are not limited to infertility, placenta accrete or previa, scar
dehiscence, and ectopic pregnancy.

Question: The patient presents for elective cesarean section. During the last pregnancy, she
had undergone a mid-transverse T incision cesarean delivery. What is the appropriate diagnosis
code assignment for a patient with a previous cesarean mid-transverse T incision scar?

Answer: Assign code O34.218, Maternal care for other type scar from previous cesarean
delivery.
 AHA Coding Clinic Guidance
AHA Coding Clinic 3rd Qtr 2020 – Inability of Fetal Head to Descend

Question: A 27-year-old female at 39 weeks gestation was admitted for

induction of labor, due to transient hypertension and favorable cervix. After
artificial rupture of membranes and induction of labor with Pitocin, she
progressed to complete dilation. Despite good maternal expulsion efforts, the
fetal vertex was never able to descend beyond +2 station, and the baby was
delivered by cesarean section. What is the appropriate code assignment to
capture a diagnosis of inability of the fetal head to descend beyond +2 station,
as the reason for the cesarean section?

Answer: Query the provider for the reason for the inability of the baby's head
to descend past +2 station and assign the appropriate code for the condition,
such as arrested labor, cephalopelvic disproportion, obstructed labor, etc.
 Weeks of Gestation
A normal pregnancy ranges
from 38 weeks to 42 weeks.
Gestational age is important as
it helps guide prenatal and
delivery care. Gestational age
simulates fetal growth, due date
determination, and treating
conditions that are pre-existing,
antepartum, during
childbirth/delivery, and
postpartum. Coding becomes
difficult when a patient is
admitted in two or more
overlapping gestational weeks.
When this happens, the
gestational age used for coding
and reporting an encounter is
using the gestational age on
admission.
 Present on Admission
When determining the Present on Admission (POA) status we must review
the medical record thoroughly and assure we are only assigning “Yes”
when the condition was present at the time of inpatient admission.

Conditions that develop after admission should contain a POA of “No”.

These are usually complications that develop during the labor and delivery
course and sometimes in the puerperium (postpartum) course.

Assigning the POA is very important and if there is ever any question as to
the correct POA assignment, we should be querying the physician for
clarification of whether the condition was present on admission or not.

See Coding Clinic Guidance related to POA status in Obstetric Encounters

on the following slide.
 AHA Coding Clinic Guidance
Coding Clinic 3rd Qtr 2019 – Progression of Pre-Eclampsia from Mild
to Severe

Question: A patient was admitted with mild pre-eclampsia that

progressed to severe pre-eclampsia during the stay. What would be the
appropriate code assignment as well as the present on admission (POA)
indicator?

Answer: Assign code O14.1 - Severe pre-eclampsia, with POA indicator

"Y" if the provider documents that mild pre-eclampsia has progressed to
severe pre-eclampsia during the same admission. When a patient
experiences deterioration or worsening of pre-eclampsia, one code is
reported for the most severe stage of the pre-eclampsia. Since pre-
eclampsia was present on admission, "Y" is the appropriate POA indicator.

Present on Admission Reporting Guidelines for obstetrical

conditions state, "The determining factor for POA assignment is whether
the pregnancy complication or obstetrical condition described by the code
was present at the time of admission or not."
 Coding COVID and Obstetrics Tips
When Coding for Obstetric patient’s with COVID exposure or COVID
infection, the Principal Diagnosis will always remain the reason for the
admission.

When coding obstetric encounters, the Chapter 15 (OB) code MUST be

the first listed diagnosis on all obstetrics admissions. Complications or
more detailed specific codes are coded as secondary diagnoses.

The coder should always review the lab results to determine if Z20.822 –
Exposure to COVID should be reported on every encounter. This should
be done on every obstetrics encounter and any other type of inpatient
encounter.

See specific obstetrics and COVID Coding Clinic guidance on the next
slide…
 AHA Coding Clinic Guidance

AHA Coding Clinic 1st Qtr 2021 – Coronavirus Infections

COVID-19 Infection (infection due to SARS-CoV-2) - Sequencing of codes

When COVID-19 meets the definition of principal diagnosis, code U07.1 -

COVID-19, should be sequenced first, followed by the appropriate codes for
associated manifestations, except when another guideline requires that
certain codes be sequenced first, such as obstetrics, sepsis, or transplant
complications.

See Section I.C.15.s. for COVID-19 infection in pregnancy, childbirth, and the
puerperium
 Parallon Specific Audit Reviews
➢ O99.02 – Anemia Complicating Childbirth

➢ O90.81 – Anemia of the Puerperium

➢ Z20.822 – Suspected Exposure to COVID

➢ O34.211 – Maternal Care for Low Transverse Scar from Previous

Cesarean Delivery

➢ O76 – Abnormality in Fetal Heart Rate and Rhythm, Complicating

Labor & Delivery

➢ O13.4 – Gestational (Pregnancy-Induced) Hypertension without

Significant Proteinuria, Complicating Childbirth

➢ O75.3 – Other Infection During Labor

➢ O85 – Puerperium Sepsis

 Parallon Specific Audit Reviews
O99.02 – Anemia Complicating Childbirth

Anemia Complicating Childbirth includes any type of anemia that is acutely

complicating the patient’s childbirth/delivery during the admission. (not the
postpartum/puerperium phase of the admission)

Instructional Notes for O99.02…

Includes conditions which complicate the pregnant state, are aggravated

by the pregnancy or are a main reason for obstetric care

Use additional code to identify the specific condition (D50.9 – Iron

Deficiency Anemia, Unspecified, or other specific anemia or nonspecific
anemia code)

Excludes1
O90.81 – Anemia arising in the puerperium
O90.81 – Postpartum Anemia, NOS
 Parallon Specific Audit Reviews

O90.81 – Anemia of the Puerperium

Anemia of the puerperium is specifically related to anemia’s that develop

AFTER delivery, within the puerperal (postpartum) stage.

Instructional Notes for O90.81…

Excludes1
O99.03 – Pre-Existing Anemia Complicating the puerperium
 Parallon Specific Audit Reviews

Z20.822 – Suspected Exposure to COVID

On every obstetric encounter that is coded, the coder must review the lab
results to determine if the patient underwent evaluation for possible COVID
infection. Whenever there is a lab result with negative COVID results,
Z20.822 must be reported on the Coding Summary

Instructional Notes for Z20.822…

Excludes1
Z22.- – Carrier of Infectious Disease
Diagnosed current infectious or parasitic disease – see Alphabetic Index

Excludes2
Z86.1- – Personal History of Infectious and Parasitic Diseases
 Parallon Specific Audit Reviews

O34.211 – Maternal Care for Low Transverse Scar from Previous

Cesarean Delivery

When a patient is admitted for obstetric care based on prior cesarean

section, this code should be sequenced as the Principal Diagnosis. (see
previous slides regarding this specific diagnosis)

Instructional Notes for O34.211…

Code First any associated obstructed labor (O65.5)

Use Additional Code for specific condition

Excludes1
Z34.- – Supervision of normal pregnancy
 Parallon Specific Audit Reviews

O76 – Abnormality in Fetal Heart Rate and Rhythm,

Complicating Labor & Delivery

This code is assigned any time the patient has evaluation or treatment
provided that is done so based on fetal heart rate and rhythm abnormalities.

Instructional Notes for O76…

Excludes1
O77.9 – Fetal Stress, NOS
O77.8 – Labor and Delivery complicated by electrocardiographic
evidence of fetal stress
O77.8 – Labor and Delivery complicated by Ultrasonic evidence of fetal
stress
 AHA Coding Clinic Guidance

Coding Clinic 4th Qtr 2013 – Meconium Amniotic Fluid and Fetal
Decelerations

Question: The provider documents meconium amniotic fluid and fetal

decelerations. What is the correct code assignment for meconium amniotic
fluid and fetal decelerations in ICD-10-CM?

Answer: Assign code O77.0 - Labor and delivery complicated by

meconium in amniotic fluid, for meconium amniotic fluid, and code O76 -
Abnormality in fetal heart rate and rhythm complicating labor and
delivery, for fetal decelerations.
 Parallon Specific Audit Reviews
O13.4 – Gestational (Pregnancy-Induced) Hypertension without
Significant Proteinuria, Complicating Childbirth

This code is assigned any time the patient is documented as having

gestational hypertension. We must assure to thoroughly review the medical
record in order to determine if the patient’s hypertension was a pre-existing
condition prior to becoming pregnant. If the patient’s hypertension is pre-
existing condition, O13.4 would not be the correct code assignment.

Instructional Notes for O13.4…

Includes
Gestation Hypertension, NOS
Transient Hypertension of Pregnancy

Excludes1
Z34.- – Supervision of Normal Pregnancy
 Parallon Specific Audit Reviews

O75.3 – Other Infection During Labor

This code is assigned When the patient is documented with sepsis “during
labor”. We must assure that the documentation supports that patient had
the condition prior to delivery, but during the admission. This code is not be
used when a patient is documented with puerperal sepsis (postpartum
sepsis).

Instructional Notes for O75.3…

Use additional code (B95-B97) to identify infectious agent

Excludes1
Z34.- – Supervision of Normal Pregnancy
 Parallon Specific Audit Reviews

O85 – Puerperium/Puerperal Sepsis

This code is assigned when the patient is documented with postpartum or

puerperal sepsis. We must assure that the documentation supports that
patient had the condition “after” delivery, not prior to delivery.

Instructional Notes for O85…

Use additional code

B95-B97, to identify infectious agent
R65.2-, to identify severe sepsis, if applicable

Excludes1
Z34.- – Supervision of Normal Pregnancy

Excludes2
O75.3 – Sepsis during labor
 References

Parallon Coding Quality Initiative Newsletter WE Ending 06/06/2022

ICD-10-CM/PCS Coding Handbook

AHA Coding Clinic Guidance