Anesthesia Coding Alert

Check out your future fall-back code for cases without indications noted.

As much as it might go against your coding instincts, sometimes you have no choice but to report a less-specific diagnosis code because the provider doesn't thoroughly document the situation. That can often be the case with labor and delivery charts, especially when the mother delivers by cesarean section.

Under current ICD-9 guidelines, you submit 669.71 (Cesarean delivery, without mention of indication, delivered with or without mention of antepartum condition) when you don't have details regarding the reason for c-section.

ICD-10 change: When ICD-10 goes into effect in October 2013, you'll still have a single code for cesarean delivery without an indication of the reason. Diagnosis O82 (Encounter for cesarean delivery without indication) will become your new option, along with related code O80 (Encounter for full-term uncomplicated delivery). You'll find both codes in Chapter 15 (Pregnancy, Childbirth and the Puerperium), subsection block Encounter for Delivery.

Documentation: Code O82 must be accompanied by a delivery code from the appropriate procedure classification. Depending on the insurance, you may also be required to include an additional code to indicate the delivery outcome from Z37.x. Some coders like to include this information anyway, although you don't always have the details available.

"Diagnosis codes are tracked for statistical information and there should be an associated reason reported for a c-section," says Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fl. "I see 669.71 much more often than I would like to see it because the anesthesia provider doesn't indicate a specific reason for the csection."

Under ICD-10, diagnosis choices for the reason for a c-section could include O61 (Failed induction of labor), O65 (Obstructed labor due to maternal pelvic abnormality), O66.4x (Failed trial of labor), or others.

Remember: Be careful to enter the letter "O" and not the numeric zero ("0") during data entry of the diagnosis codes.