The Intricacies of Women’s Health Coding for Maternal Care and Childbirth

Poor coding quality is costly, leading to denied claims, care delays, and inaccurate or slow reimbursement. Recent research finds that more than 15% of claims submitted to private payers are denied, although more than half are eventually overturned. This means providers spend excessive time appealing claims that should have been paid in the first place. The research also found that the average appeal costs more than $40 per claim, costing providers nearly $20 billion annually to adjudicate claims.

Denials are especially costly for maternal care and childbirth. The average cost related to pregnancy, childbirth, and post-partum care is $18,865, or $14,768 for vaginal births and $26,280 for cesarean sections. Since the majority of denials occur on claims over $14,000, accurate coding for these conditions is imperative.

A survey of 200 healthcare claim professionals found that authorizations, eligibility, and incorrect coding were considered the top reasons for denied claims. 

General Coding Rules for Maternal Care and Childbirth

The following are general rules coders should pay particular attention to in order to ensure timely care and optimal reimbursement.

• The Mother’s Record. Codes from Chapter 15 refer to the mother’s record only. They are never assigned on the newborn’s record.
• Sequencing and Priority. Obstetric cases require codes from Chapter 15, codes in the range O00-O9A. Chapter 15 codes have sequencing priority over the codes from other chapters. Additional codes from the other chapters may be used alongside Chapter 15 codes to specify conditions further.

The provider’s documentation of the trimester (or number of weeks) for the current admission/encounter should be the basis for the final character assignment for the trimester.

• First trimester – Less than 14 weeks, 0 days
  • Second trimester – 14 weeks, 0 days to less than 28 weeks, 0 days
  • Third trimester – 28 weeks, 0 days until delivery

• 7^th Character for Fetus Identification. Where applicable, a 7^th character is to be assigned for specific categories (O31, O32, O33.3 – O33.6, O35, O36, O40, O41, O60.1, O60.2, O64, and O69) to identify the fetus for which the complication code applies. For example: Oligohydramnios second trimester, Fetus 3 > O41.023.

Assign 7^th character “0”:

• For single gestations
  • When the documentation in the record is insufficient to determine the fetus affected and it is not possible to obtain clarification.
  • When it is not possible to clinically determine which fetus is affected.

• Completed Weeks of Gestation. In ICD-10-CM, “completed” weeks of gestation refers to the full weeks. For example, if the provider documents gestation at 39 weeks and six days, the code for 39 weeks of gestation should be assigned as the patient has not yet reached 40 completed weeks.

Complex Claims Coding

In claims coding, some areas are more complex than others. Maternal care and childbirth is one of those areas. Below are some examples of conditions that have more complex coding requirements, and therefore can have more errors.

• Pregnancy associated cardiomyopathy. This rare disorder causes a pregnant woman’s heart to become weakened and enlarged and occurs in the final month of pregnancy or in the first five months after birth.
• Code 090.3 is used only when the cardiomyopathy develops in a pregnant woman without pre-existing heart disease. It is unique as it may be diagnosed in the third trimester and continue to progress for months after the delivery.
• Puerperal sepsis. Puerperal Sepsis is a genital tract infection that occurs any time between the membrane rupture or labor and 42 days postpartum, whereupon at least two of the following conditions are present: pelvic pain, fever of 101.3 Fahrenheit, abnormal vaginal discharge, delays in the uterine involution rate.

• Code O85 must be assigned with a secondary code to identify the causal organism. For example, a bacterial infection should be assigned a code from category B95-B96, bacterial infections in conditions classified elsewhere.
• In puerperal sepsis, a code from category A40, streptococcal sepsis, or A41, other sepsis, should not be used. When applicable, use additional codes to identify severe sepsis (R65.2-) and any associated acute organ dysfunction.
• Code O85 should not be assigned for sepsis following an obstetrical procedure.

• Gestational Diabetes. Gestational diabetes, which develops in two to ten percent of U.S. pregnancies, can occur in women who didn’t already have diabetes prior to pregnancy.

• Codes for gestational diabetes are in subcategory O24.4, gestational diabetes mellitus. No other code from category O24, diabetes mellitus in pregnancy, childbirth, and the puerperium, should be used with a code from O24.4.
• Codes under subcategory O24.4 include diet controlled, insulin controlled, and controlled by oral hypoglycemic drugs.
• When a patient with gestational diabetes is treated with both diet and insulin, only the code for insulin controlled is required.

• If a gestational diabetes patient is treated with both diet and oral hypoglycemic medications, only the code for “controlled by oral hypoglycemic drugs” is required.
• Codes Z79.4, long-term (current) use of insulin, Z79.84, long-term (current) use of oral hypoglycemic drugs, and Z79.85, long-term (current) use of injectable non-insulin antidiabetic drugs, should not be assigned with subcategory O24.4 codes.

How to Develop a Highly Performing Coding Team

Building a high-performing coding team is vital, but as staffing shortages continue, it can be challenging for provider organizations to attract and retain experienced coders. One of the most effective steps they can take is to implement a comprehensive coder training program for both new and seasoned programmers.

In addition, all coders should be required to maintain certification from the AAPC or AHIMA. These certifications could be tied to compensation. The best coders will have an accuracy level of 95% and above.

When to Outsource

For organizations that lack the resources or team necessary to optimize coding quality, outsourcing can help. Shearwater Health is an excellent example. Shearwater has Six Sigma experts dedicated to a seamless A-Z implementation. Shearwater’s coding teams are prepared to handle even the most complex cases because they are also experienced clinicians.

Shearwater has more than 600 experienced, certified coders and CDI specialists and codes around seven million charts annually. Shearwater has achieved the following for its clients:

• 96% accuracy by 3^rd part quality audits
• 97% client satisfaction

If you would like to learn more about how Shearwater Health can help your organization, please contact us today.