Erica Remer, MD responds to listeners questions from the Talk Ten Tuesday broadcast Jan. 30th.

 Since I am out of town on an empty-nesting trip with my husband, I decided to answer the questions we couldn’t get to last week, in writing.

When Linda Holtzman and I were bandying about how the correct code for a condition which is neither complicating or complicated by a pregnancy would be the Z33.1 code, Pregnant state, incidental, we did not give the detail that the provider must explicitly state that the condition is not affecting the pregnancy (Official Guidelines, Section I, C. 15. a. 1). All conditions are presumed to be pregnancy-relevant unless the provider states they are not.

Many of you wrote in to point this out – thanks for the clarification. Providers will have to be trained to give the information that the “pregnant is incidental; ” it will not be intuitive or natural for them to do that for you. Linda’s example of a subcutaneous foreign body was a great example. As I mentioned before, almost ANYTHING else will fall into complicating or complicated by pregnancy!

Tammany asked: If a patient comes in with Right upper quadrant (RUQ) pain and + preg test and the diagnosis is pregnancy of unknown location, what diagnosis would you use with the pain?

The RUQ pain will be coded with R10.11. If the doctor’s documentation had just documented, “positive pregnancy test,” the code would be Z32.01, Encounter for pregnancy test, result positive. However, no provider would consider abdominal pain in pregnancy unrelated. In this case, the provider documented, “Pregnancy of unknown location” (which makes me think that he has recently been burned assuming a pregnancy was intrauterine when it was not).

My opinion is that unless and until a provider performs an ultrasound to disprove intrauterine status which would lead you to the O00- category, you just consider codes which refer to “in pregnancy, childbirth, or the puerperium” (“in pregnancy” isn’t specifying WHERE the pregnancy is). The bottom line is I think this is another opportunity to use O99.89, Other specified diseases and conditions complicating pregnancy, childbirth, and the puerperium.

Tammany also asked: What diagnosis code would you use for a nonstress test for a patient with a 2- vessel cord? Would it be O69.89?

O69.89, Labor and delivery complicated by other cord complications would be the appropriate code IF the patient was delivering. Prior to onset of labor, you wouldn’t use this code. The correlate to this code in the “maternal care for” variety is O36.89, Maternal care for other specified fetal problems. This would be the appropriate code.

Candi asked: Mom comes in for acute pancreatitis at 27 weeks. Does not deliver. Dr. lists that mom had a previous c/section. There was nothing directed towards the scar or any monitoring, treatment, etc. The code affects severity of illness (SOI) and payer is denying this citing does not meet reportable secondary diagnosis guidelines.

If having a previous cesarean delivery is relevant, such as trying to determine whether or not to try a VBAC (vaginal birth after Csxn) or to do a repeat section (either during an antepartum visit or at the time of delivery), it is obvious to use the O34.21- code set. If the provider is counseling the patient, or working up a potential uterine rupture due to the previous scar, the O34.21- codes would be applicable. The payor would not need more substantiation to consider it relevant (and worthy of increasing SOI).

The dilemma arose in this situation because “listing that there was a previous c/section” seems here to be more informational. If she were not pregnant, this clearly would be coded with: Z98.891, History of uterine scar from previous surgery.

However, since she is gravid, we must consider Coding Clinic, 2016 Q4, pp. 76-79 which states, “For a patient who is currently pregnant, a code from subcategory O34.2 should be used instead of Z98.891.”

So the choice becomes: code O34.21- (depending on type of previous Csxn) or don’t capture that information at all?

Philosophically, I do not believe in adapting coding to make payers happy. I believe in documenting to tell the truth, and coding to tell the story. The fact that we have to fight denials is unfortunate. This may be a case where you should proactively request clarification from the provider as to whether the fact that the patient had a previous cesarean section was clinically relevant or not. If the provider documents supporting evidence, it establishes legitimacy as a secondary diagnosis and should be captured.

By the way, before you all can complain: O99.613, Diseases of the digestive system complicating pregnancy, third trimester + K85.90, Acute pancreatitis without necrosis or infection, unspecified + Z3A.27, 27 weeks gestation. You guys are so tough on me!

Hope this clears up any confusion. See you in two weeks. I will be out next week, too, on an onsite visit. And a big thank you to Linda Holtzman of Clarity Coding who was our guest last Tuesday and edited this article to make sure I wasn’t making ANOTHER coding faux pas!


Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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