Normal Delivery. What does that phrase mean in ICD-10-CM coding? This month’s “In the kNOW” edition answers that question.
Normal delivery has a specific definition within ICD-10-CM. From the Official Coding Guideline I.C.15.n.1, coding professionals are directed to use code O80 “when a woman is admitted for a full-term normal delivery and delivers a single, healthy infant without any complications antepartum, during the delivery, or postpartum during the delivery episode”. This definition provides the basis for determining how to apply the phrase ‘normal delivery’.
For example, if the patient delivers a premature infant without complication could O80 be assigned? The answer is no. Remember the definition states “full-term infant”. Therefore, delivering prematurely would fall outside the realm of normal. The same would be true when the delivery is post-term. The pregnancy has progressed past full-term which again is not normal.
How about a patient who, without complication, delivers twins? Does O80 apply now? Again, the answer is no. Referring back to our definition, “a single” infant constitutes normal, but a multiple birth even without complication, does not. This is reinforced when applying guideline I.C.15.n.3 which states that only Z37.0, as the outcome of delivery code representing a single live birth, is appropriate when coding O80 for a normal delivery.
If a pregnant patient has any unresolved antepartum conditions, such as gestational diabetes or hypertension, that will tip the coding away from using the O80, normal delivery code. This is also true if any complications arise during delivery or the postpartum period occurring in the delivery episode. For example, if the patient suffers a perineal tear during delivery, the O80 code cannot be used. The same would be true if the patient developed a postpartum hemorrhage prior to discharge during the delivery episode.
What if a patient had mild bleeding in the early months of pregnancy, but it has since resolved and is not an issue at the time of delivery? Could the delivery still be considered normal? As long as no other conditions warranted coding, the answer is yes. Under guideline I.C.15.n.2, if the complication has been resolved prior to the admission for delivery, O80 may be coded.
It is possible to assign codes from other chapters of the coding manual along with O80, as long as they are unrelated to the pregnancy and not causing any complications.
Another point to remember is that O80 can only be assigned as a principal diagnosis. Therefore, for most normal delivery circumstances, O80 and Z37.0 would be the only two codes assigned.
Now you are In the kNOW!!
About the Author
She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.