ED Coding and Reimbursement Alert

Question: Can I bill for an E/M service in additional to the delivery of a baby given the chart documentation below? 

Colorado Subscriber

Patient arrived in triage screaming “I’m having a baby”, immediately wheeled into the exam room. Patient was at 40 weeks gestation G4P3 and had been having severe lower abdominal intermittent contractions for 5 hours when her water broke.  She reports this is consistent with prior deliveries.  She has not had diabetes, and she has three prior normal delivers. She denies chest pains. The remainder of history is unable to be obtained due to the imminent delivery. 

On initial exam, vital signs were stable. The gravid abdomen was tense with contractions and the baby was crowning. The ED physician applied gentle pressure to the top of the baby’s head, and there was no sign of breech, limb presentation, cord prolapse or other complicating factors. Shortly afterwards the baby was born easily via controlled normal vaginal delivery without difficulty.  There were no loops of cord around the baby’s neck. The baby was suctioned and became pink after stimulation, was moving all extremities and had a good cry without any apparent respiratory difficulties.  There were no obvious physical abnormalities.  The cord was clamped, the infant was dried, wrapped in warm blankets and placed on the mother’s belly.  The APGAR score at 1 minute was 9 (mild hypotonia), which became 10 a few minutes later. There was no significant laceration to the mother’s perineum or vagina; mucosa.

The cord remained clamped and intact, and the placenta had not yet been delivered. The mother was doing well, was no longer in obvious pain, was awake, alert and tending to her baby appropriately.  There was no significant external hemorrhage and the mother was resting comfortably and in no obvious distress. At this point the OB team had arrived and immediately transferred the mother and baby to the OB unit. 

Details From the ED Note:

The history and physical exam were limited due to the patient’s imminent delivery on arrival and subsequent rapid transfer to the OB unit after delivery.

Chief Complaint: “I’m having a baby.”

Physical exam

Constitutional: Vitals unobtainable due to patient condition and immediacy of imminent birth. Patient alert and oriented X3, but in considerable pain

Neck: Normal ROM, no jugular venous distension, no meningeal signs, cervical spine non-tender.

Head: Atraumatic, Normocephalic

Respiratory Chest:  Chest is non-tender, breath sounds normal, no respiratory distress

Cardiovasular: RRR, no murmurs, Normal S1, S2, no rub, no gallop

Abdomen: Patient obviously gravid, Patient screaming with pain, in active child birth

Upper extremity; Inspection normal, no cyanosis, no clubbing, no edema, normal range of motion, normal pulses.

Neuro: GCS is 15, no focal motor deficits, no focal sensory deficit’s, speech normal, memory normal

GU Female: external genitalia normal except for baby crowing on arrival.

Integumentary: No petechiae

Diagnosis: vaginal delivery.

Answer: Although the documentation does list numerous history and physical exam elements, any deficiencies could be covered by invoking the level 5 acuity caveat. The chart documentation does support a separately identifiable E/M service in addition to the delivery of the baby in the ED.

On the claim, you would report:

• 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity)
  
• 59409 (Vaginal delivery only [with or without episiotomy and/or forceps])

For ICD-9, a V code with a 4th digit of place of birth and a 5th digit showing whether a cesarean delivery was performed. In our example:

• V30.10 (Single liveborn, born before admission to hospital, delivered without mention of caesarian delivery)

In ICD-10 you will need to report weeks of gestation and an outcome of delivery code for the mother

• Z3A.4 0 (40 weeks gestation of pregnancy)
• Z37.0 (single live birth) 

Additionally, the baby requires a code from the Z38 section (Liveborn infants according to place of birth and type of delivery). In this case:

• Z38.00 (Single liveborn infancy born in hospital, delivered vaginally)