Severe Maternal Morbidity:ICD-10-CM/PCS
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1 Severe Maternal Morbidity:ICD-10-CM/PCS Elena Kuklina, MD, PhD, Senior Service Fellow Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health, Atlanta, GA
2 Disclaimer The opinions, findings, and conclusions in this presentation are mine and do not necessarily represent the official position of the Centers for Disease Control and Prevention. 2
3 Severe Maternal Morbidity (SMM) Algorithm: 25 indicators of SMM identified using any listed diagnosis (DX) or procedure (PR) Clinical evaluation / treatment Medical history DXs, PRs ICD codes Billing record Payment to the hospital Administrative data: National Inpatient Sample Organ-failure based (10 DXs) Management-based (7 PRs) Disease-(clinical signs and symptoms) based (8 DXs) Acute renal failure, cardiac arrest, shock, etc. Blood transfusion, hysterectomy, ventilation, etc. Eclampsia, sepsis, pulmonary embolism, etc.
4 CDC Public Health State Departments Academic Institutions / Major Medical Professional Organizations Federal organizations CDC Partners in ICD-9-CM/ICD-10-CM/PCS crosswalk for severe maternal morbidity: American College of Obstetricians and Gynecologists (ACOG) Alliance for Innovation on Maternal Health (AIM)
5 Organ-failure based 1. Acute myocardial infarction 2. Acute renal failure 3. Adult respiratory distress syndrome 4. Amniotic fluid embolism 5. Aneurysm 6. Cardiac arrest/ventricular fibrillation 7. Disseminated intravascular coagulation 8. Heart failure/arrest during procedure or surgery 9. Pulmonary edema /Acute heart failure 10. Shock
6 ICD-9-CM Issue: Diagnosis Code DX 669.4x, I97.120, I97.121, I97.130, I LABEL: Other complications of obstetrical surgery and procedures APPLIES TO Cardiac: arrest following cesarean or other obstetrical surgery or procedure, including delivery NOS failure following cesarean or other obstetrical surgery or procedure, including delivery NOS Cerebral anoxia following cesarean or other obstetrical surgery or procedure, including delivery NOS Drop 669.4x and corresponding ICD-10- CM=O75.4 based on the validation studies (MGH/UMH, CDC), prevalence/use data from states (unreasonably high)and mortality data (unreasonably low) from the NIS.
7 Management based 1. Blood transfusion 2. Cardio monitoring 3. Conversion of cardiac rhythm 4. Hysterectomy 5. Operations on heart and pericardium 6. Temporary tracheostomy 7. Ventilation
8 ICD-9-PR 35.XX-39.XX = 10,000 codes ICD-10-PCS Issue: 35.XX-37.XX 1. represented a very small group (250 cases annually in a national dataset), % of them were identified by other SMM indicators, and 3. all cases of in-hospital mortality in this group were identified among theses 60-70% cases (35.xx-37.xx + ICD-9-CM for other SMM indicators).
9 Issue: 39.XX 1. represented up to 80% of cases in this category 2. with most of them were related to repair of vessels 3. Only 30% of cases with codes 39.xx were identified by other SMM indicators, and 4. all cases of in-hospital mortality in this group were identified among theses 30% cases (39.xx + ICD-9-CM for other SMM indicators).
10 Blood transfusions 99.0x 160 ICD-10-PCS codes With 6 th digit 1. H=whole blood 2. K= Frozen plasma 3. L= Fresh Plasma 4. M=Cryoprecipitate 5. N= RBC 6. P=Frozen RBCs 7. R=Platelets 8. T=Fibrinogen Peripheral vein, percutaneous Central vein, open approach Central vein, percutaneous approach
11 Disease Based 1. Eclampsia 2. Internal injuries of thorax, abdomen, and pelvis (860.xx-869.xx) 3. Intracranial injuries (800.xx, 801.xx, 803.xx, 804.xx, 851.xx-854.xx) 4. Puerperal cerebrovascular disorders 5. Severe anesthesia complications 6. Sepsis 7. Sickle cell anemia with crisis 8. Air and thrombotic embolism
12 Why Are There So Many Diagnosis Codes? Greater specificity and detail in all diagnosis codes 34,250 (50%) of all ICD-10- CM codes are related to the musculoskeletal system 17,045 (25%) of all ICD-10- CM codes are related to fractures 10,582 (62%) of fracture codes to distinguish right vs. left 12
13 Injuries Exclude due to small # and limited # interventions among OB/GYN Delivery hospitalizations with complications Complication Weighted N Rate per 10,000 delivery hospitalizations and Standard Errors In-hospital mortality among delivery hospitalizations with complications Weighted N Percent and Standard Errors Intracranial injuries (0.01) (2.61) Internal injuries of thorax, abdomen, and pelvis (0.03) (0.64)
14
15 Steps (opportunities for miscommunication) in recording/interpretation of administrative records Clinician Diagnosis: Training, institutional practice Currently used classification/guidelines: Training, institutional practice, ambiguity Recording (quality): Varies widely, sometime without DXs, notes only Coder Interpretation: Training, institutional practice, facilityapproved abbreviation list Currently used classification / definitions: ICD-9-CM/ICD-10- CM, ambiguity The diagnosis could be coded on the hospital inpatient visit, as long as the diagnosis was not ruled out throughout the hospitalization. Recording (validity and reliability): Varies widely, sometime derives DXs based on clinician s notes
16 Steps (opportunities for miscommunication) in recording/interpretation of administrative records Clinician Eclampsia / pre-eclampsia (with and without severe features) - no longer requires proteinuria Chronic hypertension (any causes) Chronic hypertension with pre-eclampsia Gestational hypertension (*Task Force Report on Hypertension in Pregnancy by The American College of Obstetricians and Gynecologists (2013)) Coder Eclampsia Mild /moderate pre-eclampsia (*A pregnancy induced hypertensive state that occurs after 20 weeks of gestation characterized by an increase in blood pressure, along with body swelling and proteinuria) Severe pre-eclampsia Unspecified pre-eclampsia (severity) or by trimester Pre-existing hypertension (primary (with or without heart and/or chronic kidney disease) and secondary) Pre-existing hypertension with pre-eclampsia Unspecified pre-existing hypertension Gestational hypertension (without significant proteinuria) Unspecified maternal hypertension
17 Where we are? Crossing the bridge, preparing for ICD-10-CM Revising indicators based on 20- year nation wide in-hospital mortality data Developing surveillance for nonsevere maternal morbidity Pilot registry or more advanced surveillance system
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