Inpatient Facility Coding & Compliance Alert

Question: The obstetrician recommended that we report early onset of labor for a patient. He didn’t mention anything about preterm or premature labor in the record, and the delivery was spontaneous rather than induced. The patient was at 37 weeks of gestation. Is an early onset code appropriate?

Alabama Subscriber

Answer: In many situations, “less than 37 weeks” is the key to whether you report 644.21 (Early onset of delivery delivered with or without antepartum condition). If the patient has reached 37 weeks gestation or beyond, most coders don’t consider it early onset labor. Less than 37 weeks often does qualify as early onset, but don’t automatically tack 644.21 to every claim. For example, if a patient is 35 weeks pregnant and has a cesarean section due to pre-eclampsia or another complication, submitting 644.21 would be inappropriate.