ED Coding and Reimbursement Alert

Check out the most common pregnancy related diagnoses for the ED setting and get familiar with their ICD-10 equivalents.

Depending on the size and volume of your emergency department, you may not see obstetric patients for delivery, but you still need to understand the rules that apply to pregnant patients.

Non-labor related obstetric considerations frequently occur in the emergency department, says Betty Ann Price, BSN, RN, President of PRCS Inc., in Palmetto, FL. For example, serum and/or urine human chorionic gonadotropin (HCG) tests are performed for women of child-bearing age to determine pregnancy status prior to administration of medications or diagnostic radiological exams. Normal/negative HCG finding is coded ICD-9-CM V72.41 [ICD-10 Z32.02]. Abnormal/positive HCG finding is coded ICD-9-CM V72.42 [ICD-10 Z32.01].

Don’t Code the Pregnancy As Primary If That Is Not The Reason For The Visit

Often, the reason a pregnant patient presents to the ED is because she has a condition that has nothing to do with the pregnancy itself. If, within the documentation, you can confirm that the presenting problem does not relate to the patient’s pregnant state, diagnosis V22.2 (pregnancy state, incidental, [ICD-10 Z33.1] is most likely the appropriate choice to indicate status consideration, says Price.

When the patient presents with genitourinary or abdominal/ gastrointestinal complaints, seizures, diabetes, hypertension, fatigue, mental disorder, drug dependence, anemia, etc., which complicate the pregnancy, diagnosis codes 640-649 [ICD-10 O00-O9A] for complications mainly related to pregnancy are appropriate, Price adds.

Get Set For ICD-10 Specificity by Trimester and Weeks
of Gestation

In ICD-10-CM, obstetric codes found in in Chapter 15 begin with the letter "O" and not a zero. ICD-10 codes are classified by gestation trimester, rather than antepartum/postpartum 5^th digits assigned for ICD-9-CM, Price instructs.

A diagnosis of urinary tract infection during pregnancy necessitates at least two ICD-9 codes: 646.63 (Infections of genitourinary tract in pregnancy, antepartum condition or complication) and 599.0 (Urinary tract infection, site not specified).

The same diagnosis, in ICD-10, would be reported with one code: O23.4x (unspecified infection of the urinary tract). The "x" in the aforementioned ICD-10 code is a place holder where the coder could place the appropriate fifth character to represent the patient’s trimester at time of visit. The trimester options are as follows: 0 (unspecified trimester), 1 (first trimester), 2 (second trimester), and 3 (third trimester).

Tip: As always, code to the highest level of specificity; therefore, if the infection is known to be bacterial, then also report the appropriate code [ICD-9 or ICD-10] to represent the infectious agent, says Price.

Royal example: As Duchess Kate made world famous recently, morning sickness, or hyperemesis gravidarum, codes 643.0x-643.2x, are assigned by severity and/or weeks of gestation. A common coding scenario for hyperemesis gravidarum involves patients that have morning sickness in the first few weeks of their pregnancy (before 22 weeks gestation).

In ICD-9, this scenario would code out to 643.03 (mild hyperemesis gravidarum, antepartum). The appropriate ICD-10-CM code to report in this scenario is O21.0 (mild hyperemesis gravidarum, before 20 weeks gestation).

2 week difference: One additional important change between the obstetric code sets in ICD-9 vs. ICD-10 is the classification of "early" pregnancy. In ICD-9, early pregnancy is identified as "before 22 weeks gestation". Early pregnancy in ICD-10 is classified as "before completion of 20 weeks". It is important to make note of this when coding, as this two week difference could impact code selection, Price explains.

A small percentage of women with no prior history of diabetes develop abnormally high blood sugar during pregnancy. This condition is known as gestational diabetes. Don’t get caught in a trap confusing 648.03 (Diabetes mellitus, antepartum condition complicating pregnancy) [ICD-10 O24.91x] with 648.83 (Gestational diabetes) [O24.419]. A code also exists for personal history of gestational diabetes V12.21 [ICD-10 Z86.32] to describe prior pregnancy history with abnormal glucose tolerance. Prior history of gestational diabetes results in a higher risk for the condition in future pregnancies, says Price.

Look to Specific Codes for Early or Threatened Labor

Labor codes are categorized by weeks of gestation. For example, ICD-9 code 640.0x describes threatened abortion/miscarriage before 22 weeks gestation [early pregnancy]. Remembering that the classification of early pregnancy varies between ICD-9 and ICD-10, the correct code assignment for this scenario is O20.0 if, at the time of diagnosis, the patient is before 20 weeks gestation.

Another example would be a patient that presents with threatened premature labor after 22 weeks gestation but before 37 weeks gestation. In ICD-9, this would code to 644.03. The ICD-10 code assignment for this scenario would be O60.0x (preterm labor without delivery onset before 37 weeks gestation) which, depending on the gestational age, in ICD 10 would be: O60.02 Preterm labor without delivery, second trimester or O60.03 Preterm labor without delivery, third trimester, says Price.

Assign Pelvic Ultrasound Code Based on Pregnancy Status

As ultrasound technology and training expands in the ED, you should also refresh your knowledge of the relevant CPT^® codes that distinguish between pregnant uterus and pelvic (non-obstetric) ultrasounds. Code 76815 (Ultrasound, pregnant uterus, real time with image documentation, limited (e.g., fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses) describes limited ultrasound of a pregnant uterus.

There are separate ultrasound codes for pregnant transvaginal 76817(Ultrasound, pregnant uterus, real time with image documentation, transvaginal) and non-obstetric transvaginal 76830 (Ultrasound, transvaginal) approach. Providers must indicate whether a pelvic ultrasound was a transabdominal or transvaginal approach in order to assign appropriate CPT^® code.

Modifier: For ultrasound interpretation and report only, append the -26 modifier to the CPT^® code. A permanent ultrasound image should be saved to the medical record, Price warns.