Guest Post: Parsing the pregnancy problem

by Linda Renee Brown, RN, MA, CCDS, CCS, CDIP

Many CDI specialists don’t spend a lot of time working with obstetric (OB) records, or may even ignore them altogether, principally because of the ICD-9-CM Chapter 11 coding guideline that basically says that pregnancy overrides everything else. Furthermore, within MDC 14, the opportunities to affect the DRG are limited, and let’s face it, the reimbursement is abysmal at best, so the CDI team leaves it up to coding to decide what to do with these cases.

But consider what we really can do with these cases. We have occasions in MDC 14 to influence not only DRG assignment, but severity of illness (SOI), risk of mortality (ROM), length of stay (LOS), and hospital-acquired condition (HAC) management. DRG 765/766 is Cesarean section with/without complication/comorbidity (CC) or major CC (MCC). DRG 774 is vaginal delivery with complicating diagnoses, DRG 775 is without complicating diagnoses. DRG 781 and 782 are other antepartum diagnoses with or without medical complications. Right there we have a chance to look at documentation for getting the case into the appropriate DRG. At the same time, when we educate and query physicians about possible comorbidities, we can increase the SOI/ROM scores just as we do with all our other MDCs.

Consider the example of a pregnant patient diagnosed with anemia as a complicating condition prior to her Cesarean. Although Chapter 11 tells us to take complications to a pregnancy code, it also tells us to code the condition itself. If there is evidence of acute blood loss anemia (ABLA) and we do not ask the physician to clarify the diagnosis because we haven’t read the chart, then the DRG is 766, Cesarean section w/o CC/MCC, with a relative weight (RW) of 0.79, a geometric LOS of 2.90, and minor SOI . Compare that with adding documentation of ABLA, bringing the DRG to 765, Cesarean section w/CC, with a RW of 1.12, GLOS of 3.9 days, and moderate SOI.

When we choose not to review OB cases, we lose the ability to assist in documentation of present on admission diagnoses that will prevent the hospital from being charged with a (HAC). For instance, it is not impossible for a pregnant woman to have a stage III pressure ulcer, and it is certainly not unheard of for a pregnant woman to show signs of poor glycemic control such as diabetic ketoacidosis. The obstetricians need to know how to document these diagnoses to protect themselves and the hospital from unwanted and undeserved repercussions.

Then there is the exception to the rule that we all know and love: incidental pregnancy. The Official Guidelines for Coding and Reporting state:

“Should the provider document that the pregnancy is incidental to the encounter, then code V22.2 should be used in place of any Chapter 11 codes. It is the provider’s responsibility to state that the condition being treated is not affecting the pregnancy.”

So what does that mean? How do we define incidental pregnancy? I wish there was a definite rule other than “whatever the physician says it is,” but I have my thoughts.

Occasionally a chart will come onto my caseload because the admitting diagnosis was cholecystitis or a migraine, and I don’t realize until I get into the actual record that the patient is pregnant. My focus becomes determining if the principal diagnosis—the real reason they were admitted and not where it’s going to fall out under MDC 14—is unrelated to the pregnancy, and at the same time, not complicating the pregnancy. I don’t think that getting an OB consult necessarily brings us over to the pregnancy codes, but at the same time, I need to look very closely at that OB consult to see what they are doing and why they are doing it.

In my opinion, if the plan of care is being significantly altered due to the pregnancy state, I’m stuck with pregnancy. If it’s not, then I’m going to think about a query for incidental pregnancy. Maybe the pregnant woman came in because of a dog bite when she is 10 weeks pregnant, gets put on antibiotics, maybe has a minor surgical intervention. The physicians take into account the pregnancy in ordering her medications and managing her care, but it’s really not central to her admission at all. I would send that query.

I might even have a case where the patient was admitted with a broken ankle, and she didn’t even know she was pregnant until the routine bloodwork came back. I would probably send that query, too. On the other hand, I recently followed a patient who came in with an allergic reaction suspected to be due to the medications she was taking for her high risk pregnancy; she refused a CT scan because she was pregnant, and the OB team worked with the hospitalist in managing her every step of the way. I didn’t that situation was incidental and so I didn’t query for it.

I have seen coders make the decision themselves not to code the chart to MDC 14 in the absence of a physician statement, and I’ve seen cases where the physician was queried for incidental pregnancy when it was really evident that the pregnancy could not be unbundled from the medical diagnosis, and I’m not okay with either of those choices. I’m definitely an err-on-the-side-of-caution kind of girl.

So, let me know what you think. What’s your experience with the pregnant population?

Editor’s note: In the April 2010 edition of the CDI Journal readers will find an article weighing the benefits of conducting OB reviews along with a tip sheet for what to watch for. At the time of this article's original release, Brown was an independent CDI consultant based in Carrollton, GA. With experience in critical care, nursing education, disease management, case management, and long-term care, she has worked as a CDI specialist, educator, director, and consultant. She is a frequent writer on topics involving clinical documentation and published her own "The Case Manager's Quick Guide to Diagnostic Related Groups" in 2013.