Review Obstetric, Newborn Coding Guidelines

Vol. 16 •Issue 1 • Page 6
CCS Prep!

Review Obstetric, Newborn Coding Guidelines

This month’s CCS Prep! column reviews coding guidelines for obstetric and newborn coding. The review is for ICD-9-CM diagnosis coding issues only and excludes coding of abortions. Portions of the ICD-9-CM Official Guidelines for Coding and Reporting focusing on obstetrics and newborns are addressed here. However, it is important that you review the guidelines yourself after reading this article and before taking the quiz below. Guidelines found in the American Hospital Association’s Coding Clinic and ICD-9-CM Coding Handbook are also included.

Obstetric Coding

Obstetric cases require codes from Chapter 11 in the range of 630 through 677, Complications of pregnancy, childbirth and the puerperium. Only when the physician specifically documents that the pregnancy is incidental to the encounter should code V22.2, Pregnant state, incidental, be used in place of any Chapter 11 codes. It is the physician’s responsibility to state that the condition being treated is not affecting or is not affected by the pregnancy. Documentation in the medical record must indicate this. Codes from Chapter 11 have sequencing priority over codes from other chapters. Additional codes from other chapters may be used to further specify conditions. Codes from Chapter 11 are to be used only on the mother’s record and should never be used on the newborn’s record. Codes from categories 640 through 648 and 651 through 676 require fifth digits, which indicate whether the encounter is antepartum, postpartum and whether a delivery has also occurred. All codes reported during the same visit should have the same fifth digit.

For routine outpatient prenatal visits when no complications are present, codes V22.0, Supervision of normal first pregnancy, or V22.1, Supervision of other normal pregnancy, should be used as the first-listed diagnosis. A code from category V23, Supervision of high-risk pregnancy, should be the first-listed diagnosis for prenatal outpatient visits for patients with high-risk pregnancies. Codes from Chapter 11 may be used in conjunction with codes from category V23, if appropriate.

An outcome of delivery code V27.0-V27.9 should be included on every mother’s record when a hospital delivery has occurred. The fourth digit indicates whether the outcome is single or multiple and stillborn or liveborn. Codes from category V27 should not be assigned if the delivery occurred outside the hospital. A code from category V27 is only used for the visit in which the delivery occurred and is not used on the newborn record.

1. Selection of OB Principal or First-listed Diagnosis: When no delivery occurs, the principal diagnosis should be the complication of the pregnancy that necessitated the encounter. If more than one complication exists and all are treated or monitored, any of the complications may be sequenced first. When a delivery occurs, the principal diagnosis should correspond to the main circumstances or complication of the delivery. When there is a cesarean delivery, the principal diagnosis should identify the reason necessitating the cesarean delivery unless the reason for the encounter was unrelated to the reasons for the cesarean delivery.

2. Normal Delivery Code 650: Code 650 is for use in cases when a woman is admitted for a full-term normal delivery and delivers a single, healthy infant without any complications. A delivery is considered normal when it requires no or minimal assistance, with or without episiotomy, without fetal manipulation or instrumentation of a spontaneous, cephalic, vaginal, full-term, single liveborn. Code 650 may be used if the patient had a complication at some point during her pregnancy, but the complication is not present at the time of the delivery. Code 650 is always a principal diagnosis. Code 650 is not used if there is any complication. Other codes from Chapter 11 should be used instead. Additional codes from other chapters may be used with code 650 if they are not related to or are in any way complicating the pregnancy. V27.0, Single liveborn, is the only outcome of delivery code appropriate for use with 650. If there are multiple births or stillbirth, code 650 cannot be assigned.

3. Fetal Conditions Affecting the Management of the Mother: Codes from category 655, Known or suspected fetal abnormality affecting management of the mother, and category 656, Other fetal and placental problems affecting the management of the mother, are assigned only when the fetal condition is actually responsible for modifying the management of the mother. Examples of this include diagnostic studies to evaluate the abnormality or problem, additional observation, special care or termination of pregnancy. Just because a fetal condition exists does not justify the use of a code from this series.

In cases when surgery is performed on the fetus, a diagnosis code from category 655 should be assigned to identify the fetal condition. A perinatal code should not be used on the mother’s record to identify fetal conditions because surgery performed in utero on a fetus is to be coded as an obstetric encounter.

4. Current Conditions Complicating Pregnancy: Assign a code from subcategory 648, Other current conditions in the mother classifiable elsewhere but complicating pregnancy, childbirth or the puerperium, to identify current conditions that affects the management of the pregnancy, childbirth or the puerperium. Use additional secondary codes from other chapters to identify the conditions.

Diabetes mellitus is a significant complicating factor in pregnancy. Assign code 648.0x, Diabetes mellitus complicating pregnancy, and a secondary code from category 250, Diabetes mellitus to identify pregnant women who are diabetic. Code V58.67, Long-term (current) use of insulin, should also be assigned if the diabetes mellitus is being treated with insulin.

Gestational diabetes can occur during the second and third trimester of pregnancy in women who were not diabetic prior to pregnancy. Gestational diabetes can cause complications in the pregnancy similar to those of pre-existing diabetes mellitus. Gestational diabetes is coded to 648.8x, Abnormal glucose tolerance. Code 648.0x Diabetes mellitus complicating pregnancy and code 648.8x, Abnormal glucose tolerance should never be used together on the same record. Code V58.67, Long-term (current) use of insulin, should also be assigned if the gestational diabetes is being treated with insulin.

5. The Postpartum Period: The postpartum period begins immediately after and continues for 6 weeks following delivery. A postpartum complication is any complication occurring within this 6-week period. Chapter 11 codes may be used to describe postpartum complications after the 6-week period, as long as the physician documents that the condition is pregnancy related. All postpartum complications that occur during the same admission as the delivery are identified with a fifth digit of “2.” Subsequent admissions and encounters for postpartum complications are identified with a fifth digit of “4.”

When the mother delivers outside the hospital prior to admission and is admitted for routine postpartum care and no complications are noted, code V24.0, Postpartum care and examination immediately after delivery, should be assigned as the principal diagnosis. A delivery code should not be used for a woman who has delivered prior to admission to the hospital. Any postpartum procedures should be coded.

6. Late Effect of Complication of Pregnancy, Childbirth and the Puerperium: Code 677, Late effect of complication of pregnancy, childbirth and the puerperium, is assigned when an initial complication of a pregnancy develops sequelae that requires care or treatment at a later date. This code may be used at any time after the initial postpartum period and is to be sequenced following the code describing the residual condition.

Newborn Coding Guidelines

Codes from Chapter 15, Conditions originating in the perinatal period, are never for use on the mother’s record. Codes from Chapter 11, the obstetric chapter, are never permitted on the newborn record. Chapter 15 codes may be used throughout the life of the patient if the condition is still present.

The perinatal period is defined as birth through the 28th day following birth. All clinically significant conditions noted on routine newborn examination should be coded. A condition is clinically significant if it requires: clinical evaluation; therapeutic treatment; diagnostic procedures; extended length of hospital stay; increased nursing care and/or monitoring; or has implications for future health care needs.

The perinatal guidelines listed above are the same as the general coding guidelines for “additional diagnoses,” except for the final point regarding implications for future health care needs. Only the physician can determine whether or not a condition is clinically significant.

Perinatal codes should be sequenced as the principal/first-listed diagnosis on the newborn record, with the exception of the appropriate V30 code for the birth episode, followed by codes from any other chapter that provide additional detail. If the index does not provide a specific code for a perinatal condition, assign code 779.89, Other specified conditions originating in the perinatal period, followed by the code from another chapter that specifies the condition.

If a newborn has a condition that may be either due to the birth process or community acquired and the documentation does not indicate which it is, the default is due to the birth process and the code from Chapter 15 should be used. If the condition is community-acquired, a code from Chapter 15 should not be assigned.

1. Classification of Births: Assign a code from categories V30-V39 for liveborn infants according to type of birth. Type is defined as single or multiple. If multiple, the code further indicates whether mates are liveborn or stillborn, and fourth digits indicate where the birth occurred. For live births occurring in the hospital, the fifth digit indicates whether there was a cesarean delivery. A code from this series is assigned as a principal diagnosis and used only once on the newborn record at the time of birth. If the newborn is discharged and readmitted or transferred to another facility, a code from the V30 series is not used on the readmission or at the receiving hospital.

2. Additional Diagnoses: Codes from categories V30 through V39 indicate that a live birth occurred. Codes from categories 760-779 are assigned for all clinically significant conditions noted on examination of the newborn and only if the physician has documented the condition in the medical record. A condition is clinically significant if it meets the above guidelines. Conditions or signs or symptoms that resolve without treatment or require no work-up are not coded and reported. These conditions include rashes and minor jaundice.

When coding newborn sepsis, assign code 771.81, Septicemia [sepsis] of newborn, with a secondary code from category 041, Bacterial infections in conditions classified elsewhere and of unspecified site, to identify the organism. A code from category 038, Septicemia, should not be used on a newborn record because code 771.81 describes the sepsis. It is not necessary to use a code from subcategory 995.9, Systemic inflammatory response syndrome (SIRS), on a newborn record.

3. Observation and Evaluation of Newborns or Infants: Assign a code from category V29, Observation and evaluation of newborns and infants for suspected conditions not found, to identify instances when a healthy newborn is evaluated for a suspected condition that is determined after study not to be present. A code from category V29 may be used as a secondary code along with a code from categories V30-V39. It may also be assigned as a principal code for readmissions or encounters when the V30-V39 code no longer applies.

4. Maternal Causes of Perinatal Morbidity: Codes from categories 760-763, Maternal causes of perinatal morbidity and mortality, are assigned only to the newborn record and only when the mother’s condition has actually affected the fetus or newborn. The fact that the mother has an associated medical condition or experiences some complication of pregnancy, labor or delivery does not justify the assignment of codes from these categories.

5. Congenital Anomalies: Assign an appropriate code from categories 740-759, Congenital anomalies, as a secondary diagnosis when a specific abnormality is diagnosed. Congenital anomalies may also be the principal or first-listed diagnosis for encounters subsequent to the newborn admission.

If there is a code that specifically identifies the congenital anomaly, conditions that are an inherent component of the anomaly should not be coded separately. However, additional codes should be assigned for conditions that are not an inherent component. When a congenital anomaly does not have a unique code, use codes from other chapters to specify all conditions associated with the anomaly.

6. Prematurity and Fetal Growth Retardation: Codes from category 764 and subcategories 765.0 and 765.1 should not be assigned based solely upon recorded birth weight or estimated gestational age, but on the attending physician’s clinical assessment of maturity of the infant. Because physicians may utilize different criteria in determining prematurity, do not code the diagnosis of prematurity unless the physician documents this condition in the medical record. A code from the subcategory 765.2, Weeks of gestation, should be assigned as an additional code with category 764 codes and codes from subcategories 765.0 and 765.1 to specify weeks of gestation as documented by the physician.

After reviewing all of the obstetric and newborn coding guidelines, take the following quiz.

1. Code 650 for normal delivery may not be applied when:

a. the presentation is other than cephalic or vertex

b. the gestation is less than full term

c. an episiotomy is performed

d. a and b

e. all of the above

2. A 5-month pregnant female is diagnosed with iron-deficiency anemia and is sent to the clinic for a transfusion.

a. 648.23

b. 280.9, V22.2

c. 648.23, 280.9

3. A woman is readmitted 1 week after delivery with a diagnosis of delayed hemorrhage due to retained placental fragments.

a. 666.24, 623.8

b. 623.8

c. 666.24

d. 666.22

4. A woman is admitted for delivery and is given prophylactic antibiotics because she has mitral valve prolapse. The physician does not document the mitral valve prolapse as a complication of the pregnancy or a condition complicating the pregnancy.

a. 650, 424.0

b. 650

c. 648.61, 424.0

5. Newborn twin girls delivered at 35 weeks, weighing 850 grams for twin A and 900 grams for twin B. Both were diagnosed with extreme immaturity. Both would be assigned:

a. V31.00, 765.03

b. V31.00, 765.03, 765.28

c. V31.00, 765.13

d. V31.00, 765.13, 765.28

This month’s column has been prepared by Cheryl D’Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, manager of clinical HIM services, HSS, an Ingenix Company. (, which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.

Coding Clinic is published quarterly by the American Hospital Association.

CPT is a registered trademark of the American Medical Association.


1. d: Code 650 may not be assigned if the presentation is other than cephalic or vertex or if the gestation is less than full term. It is appropriate to use code 650 if an episiotomy is performed.

2. c: Codes 648.23 and 280.9 are both assigned. 648.23 is assigned because it is complicating the pregnancy, requiring transfusion. Code 280.9 is assigned to provide greater specificity as to the type of anemia.

3. c: 666.24 is the correct answer because it indicates delayed postpartum hemorrhage due to retained placenta. Only code 666.24 is required because it completely explains the circumstances.

4. c: 648.61 and 424.0 are both assigned because 648.61 identifies the pregnancy complicated by other cardiovascular disease. Code 424.0 identifies the specific condition. It is the physician’s responsibility to indicate if a condition is not complicating or is not complicated by the pregnancy. Failure to document this means that the condition is then coded as a pregnancy complication.

5. b: V31.00 is assigned to indicate twin with liveborn mate; 765.03 is assigned for extreme immaturity with weight between 750-999 grams; and 765.28 indicates 35 weeks gestation. Even though the twins were 35 weeks gestation, the documentation in the medical record indicates extreme immaturity.

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