Briefing: Obstetrics – The Whole Nine Months

1. Briefing: Obstetrics – The Whole Nine Months Date: 24 March 2010 Time: 1300–1350

2. Objectives • Describe routine obstetric care • Be able to distinguish between antepartum, intrapartum, and postpartum services • Learn the services included in delivery codes • Case examples including some common scenarios

3. The First Step of the Journey PREGNANCY TESTING • Encounters for the purpose of pregnancy testing are coded based on the results of the test or exam known at the time of the encounter. • Results of Test and/or Exam • Positive Result – code V72.42 • Negative result without any related symptoms or diagnoses – code V72.41 • Negative result with any related symptoms or diagnoses – code for symptoms or conditions plus V72.41 • Unconfirmed exam or test – code V72.40

4. Obstetrical Care UNCOMPLICATED OBSTETRICAL SERVICE CODES • Antepartum • Initial and subsequent history, physical exams • Blood pressures, urinalysis, fetal heart tones • Intrapartum (Delivery) • Admission to hospital, including admitting history and examination • Management of an uncomplicated labor • Delivery by vaginal or cesarean section • Postpartum • Hospital and/or office visits for 6 weeks after delivery

5. Obstetrical Care PREGNANCY FIRST LISTED DIAGNOSIS CODES • Routine outpatient prenatal visits when no complications are present • V22.0 Supervision of normal first pregnancy • V22.1 Supervision of other normal pregnancy • Prenatal outpatient visits for high-risk patients • V23.x Supervision of high-risk pregnancy • Secondary code may be used if appropriate

6. Antepartum • Gestational Time Periods: • Pre-term: < 37 weeks • Term: 37 to 40 weeks • Post-term: 40 to 42 weeks • Prolonged: > 42 weeks

7. Antepartum PRENATAL CARE – First Visits • First visit with nurse/diet tech for education • Code services performed as appropriate • 99499 for visit • First visit with nurse for screening, vaccinations, education (if provided) and counseling • Code services performed as appropriate • 99211 for face-to-face visit with no procedures • First prenatal encounter with privileged healthcare professional providing obstetrical care (after confirmation of pregnancy) -0500F, Initial Prenatal Care [Note: 0501F, Prenatal Flow Sheet, documented. Do not use.]

8. Antepartum PRENATAL CARE – Subsequent Visits • 0502F, Subsequent Prenatal Visits (continuing care) Use for subsequent obstetrical visits that are routine for that point in the pregnancy. This code does not include complications or issues not related to the pregnancy. • UNCOMPLICATED obstetric encounters do not have an E&M component in the 99201–99499 series • Most obstetric encounters involving complications of pregnancy do have an appropriate E&M in the 99201–99499 series and the appropriate E&M should be entered in the E&M field

9. Antepartum PRENATAL CARE – Medical Problems Complicating Pregnancy • All routine encounters for OB care will have a code from the 0500F series. Significant separately identifiable medical conditions complicating obstetric management will be coded when documented in the medical record. (See section 6.10.3.4.of coding guidelines.) • Example: A pregnant patient presents to the clinic for routine prenatal visit and has Type I diabetes, which complicates the pregnancy. • 648.03 Current conditions in the mother classifiable elsewhere, but complicating pregnancy, childbirth, or the puerperium, diabetes mellitus • 250.01 Type I diabetes, without mention of complication • Office visit E&M • 0502F Subsequent prenatal visit

10. Antepartum Complications Mainly Related to Pregnancy • Complications mainly related to pregnancy (codes 640–649) require a fifth digit • 0 – Unspecified as to episode of care or not applicable • 1 – Delivered, with or without mention of antepartum condition • 2 – Delivered, with mention of postpartum complication • 3 – Ante partum condition or complication • 4 – Postpartum condition or complication • Example: A pregnant patient presents to the clinic with excessive vaginal bleeding after being hit by a car while crossing the street. • 641.83 Antepartum hemorrhage associated with trauma • E814.7 Motor vehicle traffic accident involving collision with pedestrian • Office visit E&M

11. Antepartum • Diabetes in Pregnancy:  Difference between DM and gestational diabetes; • Report DM (defined as diabetic pre-pregnancy) • primary diagnosis of 648.0x • secondary code from category 250  • If type II DM is treated with insulin • Primary diagnosis • Secondary code from category 250 • V58.67 (long term (current) use of insulin) • Gestational diabetes • Primary diagnosis 648.8x • V58.67 if treated with insulin

12. Antepartum Prenatal Care – Visits Incidental to Pregnancy • When a patient’s pregnancy is incidental to other services rendered, the provider must state the pregnancy does not affect care • Code the pregnant state with V22.2 diagnosis code as a secondary diagnosis • Example: A three-month-pregnant patient fell from a ski chair-lift while skiing and fractured her wrist • Chief complaint is wrist fracture, 814.xx • E847 Accidents involving cable cars not running on rails • V22.2 Pregnant state, incidental • Office visit E&M • Procedure code for treatment of the fracture

13. Antepartum Examples of Separately Reportable Services • Additional medically indicated ultrasound • Echocardiography • Fetal biophysical profile • Amniocentesis, cordocentesis • Chorionic villus sampling • Fetal contraction stress test • Fetal non-stress test • Hospital admission and observation for preterm labor, except within 24 hours of delivery • Management of surgical problems arising during pregnancy (e.g., appendicitis, incompetent cervix, ruptured uterus)

14. Antepartum • Coding for Multiple Gestations – Ultrasound • 76801 Obstetrical US: Pregnancy < 14 Weeks; single or first gestation • 76802 for each additional gestation (no modifier) • 76805 Obstetrical US: Pregnancy of 14 Weeks or more; single or first gestation • 76810 for each additional gestation (no modifier) • 76815 Ultrasound, pregnant uterus, real time with image documentation, limited, 1 or more fetuses • 76816 * Ultrasound, pregnant uterus, real time with image, transabdominal approach, per fetus * Use units of service for # of fetus’ and modifier -59 due to ADM system limitation

15. OB Observation If There Is No Order for Observation • For clinic services, use E/M code 9921X based on documentation. For Emergency Department services, use E/M 9928x based on documentation. In those instances when a non-emergency service is provided by a non-emergency provider (e.g., obstetrician treats patient in the Emergency Department on a weekend when the OB clinic is closed), code the services as clinic services. • If more than 70 minutes (99215 = 40 minutes, prolonged service 99354 = 30 minutes) is spent face-to-face with the patient and the total time and Provider’s activities during that time are documented in the medical record, code 99215 and 99354 for clinic or 99285 only for Emergency Department. • Code for fetal stress/non-stress/monitoring in addition to the E/M code

16. OB Observation If There Is an Order for Observation • Provider documents written order for observation, no delivery on same date of service (99218–99220). Diagnosis will reflect medical necessity. Observation services are outpatient services. Therefore, if the patient is observed for a condition not verified, code the symptoms. Do not use the V71 Observation for Condition not found. • To generate a codable encounter, an appointment must be created manually for each day of observation • Provider documents written order for observation. If no delivery on subsequent date of service, use E/M 99218–99220 • Provider documents written order for observation. No delivery, discharged same date of service, use E/M 99234–99236 • Provider documents written order for observation. No delivery, discharged on subsequent date of service, use E/M 99217 for the last day of observation

17. OB Observation Patient Is in Observation, Is Admitted, and Delivers the Same Date • 1. Observation: Close out the observation using the 0502F for routine prenatal and labor. Complications are coded based on documentation. • 2. Admission: The round (RND) encounter for this day may have an E/M based on documentation and the procedure will be the delivery (vaginal 59409; cesarean section 59514). This is an MHS deviation from civilian standards of coding.

18. OB Observation Patient Is in Observation and Is Admitted and Does Not Deliver During this Admission • 1. Observation: Close out the observation using the 0502F for routine prenatal care and labor. Complications are coded based on documentation. • 2. Admission: The RNDs encounter will be based on the documentation from the time of admission.

19. Outcome of Delivery Delivery Diagnoses • Outcome of Delivery Codes, V27.x • These codes are used on the mother’s record at delivery and will appear on the inpatient rounds encounter if delivered at the MTF • Live-born Infants According to Type of Birth, Codes V30–V39.x • These codes are used on the infant’s record

20. OB Observation Patient Delivers on the Second Date of Observation Status • Observation: Code the observation encounter for day 1 using the 0502F for routine prenatal care and labor. Complications are coded based on documentation. • Code the observation encounter for day 2 using the 0502F for routine prenatal care and labor. • Admission: The RNDs encounter will be based on the documentation from the time of admission. Use appropriate delivery codes based on documentation.

21. OB Observation Patient Delivers on the Second Date of Observation Status • Observation: Code the observation encounter for day 1 using the 0502F for routine prenatal care and labor. Complications are coded based on documentation • Code the observation encounter for day 2 using the 0502F for routine prenatal care and labor • Admission: The RNDs encounter will be based on the documentation from the time of admission. Use appropriate delivery codes based on documentation

22. OB with Normal Delivery – Example 1 Patient admitted in labor. Baby was delivered the following day. There were no complications during delivery or during admission.

23. Routine Obstetric Care Global Routine Care – do not use 59400 Vaginal delivery 59510 Cesarean delivery 59610 Vaginal delivery after a previous cesarean 59618 Cesarean delivery following an attempted vaginal delivery after previous cesarean delivery

24. Routine Obstetric Care Non-Global Routine Care – used by the MHS 59409 Vaginal delivery only 59514 Cesarean delivery only 59612 Vaginal delivery only, after a previous cesarean 59620 Cesarean delivery only, following an attempted vaginal delivery after previous cesarean delivery Excluded antepartum services (report separately when performed) Insertion of cervical dilator by physician prior to day of delivery (59200) External cephalic version (59412)

25. Routine Obstetric Care Multiple Births • Vaginal birth: Code 59409 (or 59612 for a vaginal birth after a previous C-section (VBAC)) with a unit of the number of newborns • C-Section: Code 59514 (or 59620 for a VBAC that results in a C-section), with a unit of service of 1. There is only one C-section • Multiple births with at least one vaginal and one C-section are coded with the appropriate type of vaginal birth code and the number of vaginal births using the unit’s field. Code the appropriate C-section code with a unit of service of 1 for all the infants delivered by the one C-section

26. Multiple Gestation, Fetus Loss Fetus(es) loss in multiple gestation:  • Twin pregnancy with a loss of one and retention of one, report 651.3x • Triplet pregnancy with a fetal loss and retention of one or more fetus(es), report 651.4x • Quad pregnancy 651.5x; more than quads-report651.6x (all with at least one fetal loss and one fetal retention)  • Elective fetal reduction for multiple gestations* • CPT is 59866 and • Diagnosis is 651.7x • * Check with your Service Mgr. if a covered procedure

27. Routine Obstetric Care 59409 Vaginal Delivery Only (with or without episiotomy and/or forceps) • Included intrapartum services: • Management of uncomplicated labor including fetal monitoring • Preparation of the perineum with antiseptic solution • Vaginal delivery with or without forceps or vacuum extraction • Delivery of the placenta, any method • Episiotomy and repair/suturing of lacerations • Injection of local anesthesia • Placement of internal fetal and/or uterine monitors • Catheterization or catheter insertion • Administration of intravenous oxytocin • Simple removal of cerclage (not under anesthesia) • Exploration of uterus • Placement of a hemostatic pack or agent

28. Routine Obstetric Care 59409 Services Reported Separately When Performed • Excluded intrapartum services: • Fetal scalp blood sampling (59030) • Administration of regional anesthesia (62311, 62319, 64430, or 64435) • Excluded postpartum services: • Uncomplicated inpatient hospital postpartum visits • Tubal ligation (58605)

29. Routine Obstetric Care 59514 Cesarean Delivery Only • Included intrapartum services: • Management of labor including fetal monitoring • Preoperative counseling including rationale for cesarean delivery • Catheterization or catheter insertion • Preparation of abdomen • Abdominal incision • Incision into uterus with delivery of fetus, placenta and fetal membranes • Exploration of uterus • Uterine repair • Hemostasis • Wound closure • Injection of local anesthesia • Placement of internal fetal and/or uterine monitors • Administration of intravenous oxytocin • Simple removal of cerclage (not under anesthesia)

30. Routine Obstetric Care 59514 Services Reported Separately When Performed • Excluded intrapartum services: • Any gynecologic surgery • Bowel repair (44604) • Cystotomy, cystotomy with drainage (51040) • Bladder cystotomy to excise lesions (51530) • Tubal ligation at the time of cesarean delivery (58611) • Lysis of extensive, dense adnexal adhesions (58740) • Fetal scalp blood sampling (59030) • Hysterectomy at the time of cesarean delivery (59525) • Administration of regional anesthesia (62311, 62319, 64430, or 64435) • Administration of Rh immune globulin (90772) • Excluded postpartum services: • Uncomplicated inpatient hospital postpartum visits • Management of inpatient medical problems related or unrelated to the pregnancy

31. Routine Obstetric Care 59612 Vaginal Delivery Only, After Previous Cesarean Delivery (with or without episiotomy and/or forceps): • Included intrapartum services: • Management of uncomplicated labor including fetal monitoring • Preparation of the perineum with antiseptic solution • Vaginal delivery with or without forceps or vacuum extraction • Delivery of the placenta, any method • Episiotomy and repair/suturing of lacerations • Injection of local anesthesia • Placement of internal fetal and/or uterine monitors • Catheterization or catheter insertion • Administration of intravenous oxytocin • Exploration of uterus and previous cesarean scar • Placement of a hemostatic pack or agent • Simple removal of cerclage (not under anesthesia)

32. OB with Planned C-Section – Example 2 Patient admitted for planned C-section. There were no complications during delivery or admission

33. Routine Obstetric Care 59612 Services Reported Separately When Performed • Excluded intrapartum services: • Fetal scalp blood sampling (59030) • Administration of regional anesthesia (62311, 62319, 64430, or 64435) • Excluded postpartum services: • Management of inpatient medical problems related or unrelated to the pregnancy • Tubal ligation (58605)

34. Routine Obstetric Care 59620 Cesarean Delivery Only, Following Attempted Vaginal Delivery After Previous Cesarean Delivery • Included intrapartum services: • Management of labor including fetal monitoring • Preoperative counseling including rationale for cesarean delivery • Placement of internal fetal and/or uterine monitors • Catheterization or catheter insertion • Preparation of abdomen • Abdominal incision • Incision into uterus with delivery of fetus, placenta and fetal membranes • Exploration of uterus • Uterine repair • Hemostasis • Wound closure • Injection of local anesthesia • Administration of intravenous oxytocin • Simple removal of cerclage (not under anesthesia)

35. Routine Obstetric Care 59620 Services Reported Separately When Performed • Excluded intrapartum services: • Fetal scalp blood sampling (59030) • Injection of regional anesthesia (62311, 62319, 64430, or 64435) • Administration of Rh immune globulin (90772) • Excluded postpartum services: • Uncomplicated inpatient hospital postpartum visits • Management of inpatient medical problems unrelated to the pregnancy

36. Complications during Labor & Delivery • Complications occurring mainly in the course of labor and delivery (codes 660–669) require a fifth digit • 0 – Unspecified as to episode of care or not applicable • 1 – Delivered, with or without mention of antepartum condition • 2 – Delivered, with mention of postpartum complication • 3 – Ante partum condition or complication • 4 – Postpartum condition or complication • Example: • Cord around neck, with compression 663.11 • Fetal distress 656.31

37. Complications • Complications of the Puerperium (codes 670–677) require a fifth digit • 0 – Unspecified as to episode of care or not applicable • 1 – Delivered, with or without mention of antepartum condition • 2 – Delivered, with mention of postpartum complication • 3 – Ante partum condition or complication • 4 – Postpartum condition or complication • Example: • Major puerperal infection, delivered (developed while in the hospital) 670.22

38. Postpartum Uncomplicated Postpartum Care • V24.2 Routine postpartum follow-up • 0503F for one uncomplicated outpatient visit by the same group practice that performed the delivery. • Code all other postpartum encounters with the appropriate established patient E&M code or post-op code • 59430 uncomplicated outpatient postpartum follow-up by a group practice other than the group practice that performed the delivery NOTE: V24.0, Postpartum care and examination immediately after delivery, is only assigned as the principal diagnosis if the mother delivers outside the hospital prior to admission and is admitted for routine postpartum care and no complications are noted

39. ACOG Can Help ACOG can help with your OB/GYN coding problems OB/GYN CPT Coding Manual ICD-9-CM “Abridged” Diagnostic Coding in OB/GYN Frequently Asked Questions in OB/GYN Coding Essential Guide to Coding in OB/GYN 13 Coding Workshops each year 6 Coding Webcasts each year Send in your OB/GYN coding questions to Coding@acog.org

40. Summary • Complications as coded differently from routine visits • To code routine obstetric services use the non-global codes • Some services are excluded from the delivery codes and may be coded separately

41. Quiz • Does the MHS use global OB codes? • Can you code an E&M service if the visit is for a complication? • If the pregnancy does not seem to impact the visit but the provider does not state that in the documentation, can you code it as incidental?