The Right Combination for High-Risk Pregnancy Dx

From diabetes to multiple gestation complication, correct code sequencing is essential.

By Pamela K. Kostantenaco, LPN, CPC, CMC

In the world of high-risk pregnancies, it is important that you code the maternal or fetal conditions accordingly. Correct sequencing is especially important in cases where multiple codes are needed.

General Guidelines

When selecting a diagnosis code for obstetrical cases, look to the ICD-9-CM manual, chapter 11, “Complications of Pregnancy, Childbirth, and the Puerperium (630-679).” Important general rules for obstetric cases include the following:

  • If the physician documents the pregnancy is incidental to an encounter, use V22.2 Pregnant state, incidental in place of any chapter 11 codes. It is the physician’s responsibility to state that the treated condition is not affecting the pregnancy.
  • Chapter 11 codes have sequencing priority over codes from other chapters. You can use additional codes from other chapters with chapter 11 codes to further specify conditions.
  • Categories 640-648 and 651-676 require fifth digits, which indicate whether the encounter is antepartum or post-partum, and whether a delivery occurred.

Diabetes in Pregnancy

When the physician or practitioner writes “diabetes” in the medical record, be very sure you select the correct code(s). In auditing practices over the years, I have seen a lot of confusion in this area.

For example, consider diabetes mellitus and gestational diabetes—two different conditions with separate diagnosis codes. Diabetes mellitus is a significant complicating factor in a pregnancy. Report diabetes mellitus (defined as diabetic pre-pregnancy) with the primary diagnosis code 648.0x Diabetes mellitus complicating pregnancy, and a secondary code from category 250 Diabetes mellitus, or category 249 Secondary diabetes mellitus to identify the type of diabetes. If the diabetes mellitus is treated with insulin, assign V58.67 Long-term (current) use of insulin, as well.

Gestational diabetes can occur during the second and third trimester of pregnancy in women who were not diabetic prior to pregnancy. Gestational diabetes can cause complications in the pregnancy similar to those of pre-existing diabetes mellitus. It also puts a woman at greater risk of developing diabetes after the pregnancy. Gestational diabetes is coded 648.8x Abnormal glucose tolerance. Assign code V58.67 also if the gestational diabetes is treated with insulin.

For the preceding examples, you would report two or three ICD-9-CM codes. By coding in this manner, you are providing payers with the most accurate diagnosis on this patient. In some instances, this assists you in obtaining necessary authorizations for serial antepartum testing and other services.

Understand the Fifth Digit

Selecting the correct fifth digit is very important in defining the episode of care. Use the following fifth-digit sub-classification with specific categories to denote the current episode of care:

0 = unspecified as to episode of care or not applicable

1 = patient has delivered, with or without mention of antepartum condition

2 = patient has delivered, with mention of postpartum complication

3 = antepartum condition or complication (currently pregnant)

4 = postpartum condition or complication (patient has delivered)

The postpartum period begins immediately after delivery and continues for six weeks following delivery. A postpartum complication is a complication occurring within the six-week period. Postpartum complications occurring during the same admission as the delivery are identified with a fifth digit of “2.” Identify subsequent admissions/encounters for postpartum complications with a fifth digit of “4.”

Diagnosis Codes for Multiple Gestations

With the ongoing advancement in the reproductive technology field, it is very important to understand the different types of multiple gestations. This sort of knowledge will enable you to select the proper diagnosis code(s).

When multiple gestations are involved, selecting a diagnosis code can be somewhat confusing. For example, the medical record may state: “twins, mono/mono,” “twins, mo/mo,” “twins, mono/di,” “twins, di/di,” “twin-to-twin transfusion syndrome (TTTS),” etc.

On Oct. 1, 2008 two codes were released for specific twin conditions:

  • Fetal conjoined twins are reported as code 678.1x.
  • When TTTS has been diagnosed, report two codes: 651.0x Twin pregnancy (be sure to report twin gestation as primary) with 678.0x Fetal hematologic conditions.

Note: Code 678.0x also can be reported when fetal anemia or fetal thrombocytopenia has been diagnosed on a single gestation.

TTTS occurs specifically in identical twins sharing the same placenta. It is estimated to occur in 5 to 10 percent of identical twin pregnancies. In TTTS, the twins share not only the same placenta but some of the same circulation. This allows the transfusion of blood from one twin (the donor) to the other (the recipient). The donor twin becomes small and anemic, and the recipient twin becomes large and overloaded with blood. Because the recipient twin has more blood, he or she also urinates more and has more amniotic fluid. The donor twin has less amniotic fluid; sometimes there is so little fluid the fetus appears on ultrasound to be stuck in place on the wall of the uterus (known as stuck twin phenomenon).

Twin-to-twin transfusion syndrome should not be confused with the condition twin oligohydramnios-polyhydramnios sequence (TOPS). For this you would report three codes: 651.0x, 658.0x Oligohydramnios, and 657.0x Polyhydramnios.

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