Q What diagnosis should be reported for an induced delivery at 30 weeks for preeclampsia?
A The answer depends on whether you induced labor for delivery or went immediately to a cesarean delivery.
In either case, report the ICD-9-CM code that supports the type of preeclampsia (eg, 642.51, severe preeclampsia; delivered with or without mention of antepartum condition). But if labor was induced, add code 644.21 (early onset of delivery; delivered with or without mention of antepartum condition). This code represents premature labor with delivery before 37 completed weeks of gestation.
If the delivery was accomplished by performing a cesarean, in addition to an outcome code such as V27.0 (single liveborn), you might add a code if the patient had a previous cesarean delivery (654.21).
If this was her first cesarean delivery, only the preeclampsia and outcome diagnosis codes would be assigned.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.