Severe maternal morbidity often intersects with cesarean deliveries.
Reducing the number of cesarean deliveries can lower the maternal mortality rate, and one of the drivers of cesarean rates is thought to be induction of labor (IOL). In 2014, the American College of Obstetricians and Gynecologists (ACOG) adopted definitions for labor, labor induction, and augmentation of labor, which are helpful for coders in determining when a code for IOL is appropriate.
ACOG defines labor as:
ACOG STANDARD LABOR DEFINITIONS (2014):
Uterine contractions resulting in cervical change (dilation and/or effacement)
- Latent phase – from the onset of labor to the onset of the active phase
- Active phase – accelerated cervical dilation typically beginning at 6cm
There are various methods that can be used to induce labor, including cervical ripening, Pitocin administration, cervical dilation, and artificial rupture of membranes (AROM). This article addresses each type and the coding associated with them.
Cervical Ripening with Prostaglandins
The cervix is normally a very firm structure, but for vaginal delivery, it needs to be soft. Cervical ripening agents known as prostaglandins are used to soften the cervix. There are two main types of prostaglandins used in IOL: Cytotec (misoprostol) and Cervidil (dinoprostone). Although they both act to soften the cervix, they are different products, with variations that impact code assignment.
Cytotec is a pill that gets absorbed through the mucosal membrane and can be administered orally, vaginally, or rectally. Once administered, it can’t be taken back, and can lead to overstimulation of the uterus, thereby instituting very strong uterine contractions. When given for induction of labor, Cytotec is administered either orally or vaginally. It is also often administered rectally after delivery to stop postpartum hemorrhage.
Cervidil is a ribbon-like vaginal insert that is placed just behind the cervix. Unlike Cytotec, it can be removed once the patient reaches active labor, and will not overstimulate the uterus.
The Coding Clinic for ICD-10-CM/PCS published for the second quarter of 2014, Page 8, directs coders to assign code 3E0P7GC (Introduction of other therapeutic substance into female reproductive, via natural or artificial opening) for cervical ripening using Cervidil. There is no official published advice for reporting Cytotec induction, but this same code can be used for vaginal administration of Cytotec. Most facilities do not capture oral administration of medication, but should consider assigning code 3E0DXGC (Introduction of other therapeutic substance into mouth and pharynx, external approach) when Cytotec is given orally to induce labor. This will help researchers capture all cases of prostaglandin induction.
While cervical ripening can cause contractions, most patients will also need Pitocin. Pitocin is a synthetic version of the hormone oxytocin, which initiates uterine contractions. It is administered through intravenous infusion to either start or improve the quality of weak contractions. When given to initiate labor, it is referred to as induction. When given to strengthen uterine contractions, it is called augmentation.
ACOG STANDARD LABOR DEFINITIONS (2014)
AUGMENTATION OF LABOR
The stimulation of uterine contractions using pharmacologic methods or artificial rupture of membranes to increase their frequency and/or strength following the onset of spontaneous labor or contractions following spontaneous rupture of membranes.
If labor has been started using any method of induction described below (including cervical ripening agents), then the term Augmentation of Labor should not be used.
INDUCTION OF LABOR
The use of pharmacological and/or mechanical methods to initiate labor (examples of methods include but are not limited to artificial rupture of membranes, balloons, oxytocin, prostaglandin, Laminaria, or other cervical ripening agents).
Still applies even if any of the following are performed:
- Unsuccessful attempts at initiating labor
- Initiation of labor following spontaneous ruptured membranes without contractions
The distinction between induction and augmentation is critical for coders, because Coding Clinic advises us not to code for augmentation. Pitocin induction is reported with code 3E033VJ (Introduction of other hormone into peripheral vein, percutaneous approach).
Balloon Dilation of the Cervix
Another method for inducing labor is the mechanical dilation of the cervix. This is often performed with a balloon, which gently dilates the cervix over an extended time. This procedure is reported with a code from the Medical and Surgical section of PCS for dilation of the cervix (0U7C7ZZ, Dilation of cervix, via natural or artificial opening).
In most instances, the data captured with ICD-10-PCS codes is far superior to that of their ICD-9-CM counterparts. One exception is AROM for IOL. In ICD-9-CM, code 73.01 (Induction of labor by artificial rupture of membranes) was very specific to rupturing membranes to jump-start labor. Since ICD-10-PCS does not include any diagnostic data, this is a data element we lost. Rupture of membranes, for induction or otherwise, is reported with a single code: 10907ZC (Drainage of amniotic fluid, therapeutic from products of conception, via natural or artificial opening).
One potential opportunity for identifying patients who experience amniotomy for IOL lies in the sequencing of diagnosis codes. Guidelines for sequencing the principal diagnosis for both vaginal and cesarean deliveries are tricky at best, but it is important to remember that when a patient is admitted for IOL, the indication for the induction is sequenced first, as outlined in the coding guidelines and the Coding Clinic published for the first quarter of 2016, Page 3.
Bringing it all Together
As with other areas of coding for obstetrics, complete and consistent reporting of IOL codes can help researchers identify elements that impact maternal morbidity. This is a great time to develop internal guidelines and tighten up the coding for consistent reporting.
For More Information: https://www.icd10monitor.com/the-impact-of-coding-on-maternal-outcomes-part-iii