Ob-Gyn Coding Alert

Hint: You should always include an additional code to indicate delivery outcome.

C-section coding can seem simple — until you have to navigate the tricky landscape of diagnosis coding. A planned c-section diagnosis may rely upon the mother’s scar, so make sure your ob-gyn’s documentation—and your claim—is picture perfect.

Challenge 1: How Should You Report Elective C-Section?

Solution: When a patient requests an elective primary C-section, the appropriate diagnosis code will require digging into the documentation for the rationale. By definition, a primary cesarean means that the patient has never had a cesarean delivery in the past. If the patient simply requests a cesarean and the ob-gyn does not document any medical indication at all, you will report O82 (Encounter for cesarean delivery without indication) followed by an outcome of delivery code such as Z37.0 (Single live birth).

“This should be a rare occurrence, however, as a cesarean birth raises patient and fetal risk and is usually not performed without extensive discussions between the patient and physician. Therefore, the coder must carefully examine the documentation to determine the reason for this cesarean,” says Ashley Zyduck, CPC, CPB, CENTC, COBGC, lead physician coder for Medkoder in Jackson, Missouri.

Reasons will vary, but it might be that the patient has had a previous uterine surgery for fibroids (O34.29, Maternal care due to uterine scar from other previous surgery), a pelvic anomaly that makes vaginal birth impossible (O34.8-, Maternal care for other abnormalities of pelvic organs), or even be the result of a patient who has a fear of labor (O99.34-, Other mental disorders complicating pregnancy, childbirth, and the puerperium). When the ob-gyn identifies a reason, you should always list an indication first.

A final option would be O75.82 (Onset (spontaneous) of labor after 37 completed weeks of gestation but before 39 completed weeks gestation, with delivery by (planned) cesarean section) as long as the criteria are met: i.e, the patient’s primary cesarean was planned in advance; she went into labor prior to 39 completed weeks; and the reason for the cesarean has not changed. When you report this code, you should consider it secondary as the reason for the planned cesarean will always be listed first.

Challenge 2: How Should You Report a Repeat C-Section With Pelvic Adhesions?

First, let’s expound upon this scenario. Suppose the patient had a repeat global C-section and underwent a T incision on the uterus. The patient had adhesions, and that’s why the ob-gyn had to do the T incision. Note states, “dense adhesions of the bladder to the lower uterine segment made it not possible to grasp the uterine visceral peritoneum. Therefore, I made my uterine incision above the area of the adhesions... I was unable to guide the head through the incision, I teed to the incision in the midline. I then used the kiwi vacuum to help guide the head out of the incision....” What should you report?

Solution: C-section, says Melanie Witt, RN, MA, an ob-gyn coding expert based in Guadalupita, N.M. Was it a repeat T-incision C-section? Or was there some other pressing reason for the cesarean, such as a breech position or fetal distress? Do you know if this was a failed induction? You would not report O34.211 unless the previous cesarean was performed via a low transverse incision. To find that out, you may have to dig into her history or consult with the provider. If the previous cesarean was performed with a normal incision, you would report O34.212 (Maternal care for vertical scar from previous cesarean delivery).

Remember, you can only link four diagnosis codes to a charge, so you could report an O34 code, N73.6 (Female pelvic peritoneal adhesions (postinfective)), then the patient’s weeks of gestation, and then the outcome of birth. That being said, if you can find a diagnosis that pertains more to the entire pregnancy or reason for the C-section, you should report that in place of N73.6.

Challenge 3: What Dx Should You Use for “C-Section Wound Seroma?”

Solution: Your diagnosis code would be either O90.2 (Hematoma of obstetric wound) or O86.0 (Infection of obstetric surgical wound). Obviously, a seroma, which is a fluid filled sac, is neither a hematoma nor a wound infection, so this is a case where you might not have an exact code.

When looking up the term “seroma” in the ICD-10-CM index, you will see a comment “see also hematoma.” While this is not exactly like saying that you should code a seroma and hematoma the same, you won’t find any specific codes for a seroma following a cesarean. Another possibility, however, would be to report O90.89 (Other complications of the puerperium, not elsewhere classified).