New Guideline I.C.15.l.3 Drug use during pregnancy, childbirth and the puerperium, and New Codes for Chapter 16 Certain Conditions Originating in the Perinatal Period.March 11, 2019
The World Health Organization (WHO) notes, “Use of alcohol, illicit drugs and other psychoactive substances during pregnancy can lead to multiple health and social problems for both mother and child, including miscarriage, stillbirth, low birthweight, prematurity, physical malformations and neurological damage.”
Complete and accurate coding as well as application of the FY2019 Official Coding Guidelines (OCG) I.C.15.l, Alcohol, tobacco and drug use (italicized words added) during pregnancy, childbirth and the puerperium helps provide the data for “identification and management of alcohol and other substance use and substance use disorders in pregnant women, with the target of healthy outcomes for both the pregnant women and their fetus or infant.”
New Guideline for “drug use”
Effective October 1, 2018, there was a title revision of guideline I.C.15.l, Alcohol, tobacco and drug use (italicized words added) during pregnancy, childbirth and the puerperium. The title change corresponds to the new official coding guideline (OCG) added to this section that addresses drug use, guideline I.C.15.l.3, Pregnancy, Childbirth, and the Puerperium. Guidelines for alcohol use and tobacco use were already present in this guideline section.
Here is the new OCG I.C.15.l.3:
“Drug use during pregnancy, childbirth and the puerperium. Codes under subcategory O99.32, Drug use complicating pregnancy, childbirth, and the puerperium should be assigned for any pregnancy case when a mother uses drugs during the pregnancy or postpartum. This can involve illegal drugs, or inappropriate use or abuse of prescription drugs. Secondary code(s) from categories F11-F16 and F18-F19 should also be assigned to identify manifestations of the drug use.”
Already present were the codes for drug use during pregnancy, childbirth and puerperium (O99.32-), as well as entries in the Index directing the coder to the Tabular List category O99.32-. Note that these codes are further specified as to trimester. See the instruction note in this code category “Use additional code(s) from F11-F16 and F18-F19 to identify manifestations of drug use.” These drugs and their manifestations are:
F11 Opioid related disorders
F12 Cannabis related disorders
F13 Sedative, hypnotic, anxiolytic related disorders
F14 Cocaine related disorders
F15 Other stimulant related disorders
F16 Hallucinogen related disorders
F18 Inhalant related disorders
F19 Other psychoactive substance related disorders
Code Category F17 Nicotine dependence is not included in this list for this guideline because it pertains to the guideline for tobacco use, not drug use.
Note that none of the drugs listed in the categories above include the terms “illegal,” or for “prescription use” in their code descriptions. The new guideline, however, clarifies, “This can involve illegal drugs or inappropriate use of prescription drugs” and enables capture of any drug or drugs involved, regardless of the legality or source of the drug.
When using the additional code(s) from F11-F16 and F18-F19, the OCGs from Chapter 5. Mental, Behavioral and Neurodevelopmental Disorders must also be applied.
A review of OCG I.C.5.b. Mental and behavioral disorders due to psychoactive substance use, subsections 1), 2) and 3) specify that these codes (as in the categories listed above) are reported only when
- There is provider documentation of drug use, abuse or dependence. If more than one of these terms is documented, assign based on the hierarchy in the OCG. For example, “If both use and abuse are documented, assign only the code for abuse.”
- If the drug use, abuse or dependence is not well documented or appears historical, it cannot be assumed “in remission;” the provider must document “in remission.”
- If documented as “use” and not further specified, “These codes are to be assigned only when the psychoactive substance use is associated with a physical, mental or behavioral disorder, and such a relationship is documented by the provider.”
- They meet the definition of a reportable diagnosis (see Section III. Reporting Additional Diagnoses).
Example 1: A 26 year old woman presents through the ED for delivery of a full term infant at 37 weeks. She has a history of smoking recreational marijuana noted in her history and physical, and upon examination is noted to have mild symptoms of cannabis intoxication. A drug screen performed on admission is positive for cannabis. The provider documents “cannabis use and abuse with intoxication.” She is referred to social services and her baby is referred to child protective services for follow-up.
Report these diagnosis codes:
O99.324 Drug use complicating childbirth
F12.120 Cannabis abuse with intoxication, unspecified
Z3A.37 37 weeks gestation of pregnancy
Z37.0 Single live birth
Rationale: The patient’s cannabis abuse complicated her pregnancy and her encounter for delivery. The provider documented “use” and “abuse,” so the code for “abuse” is reported. The provider specified cannabis “intoxication” only, reported as “unspecified.”
Example 2: A 32 year old woman presents for a repeat low-transverse cesarean section at 39 weeks, delivering a healthy newborn. Her history and physical mentions past history of an anxiety disorder during her teenage years, for which she was prescribed Xanax. She related that during this time, she abused the Xanax at a party. She no longer has anxiety and hasn’t taken Xanax for 15 years.
Report these diagnosis codes:
O34.211 Maternal care for low transverse scar from previous cesarean delivery
Z3A.39 39 weeks gestation of pregnancy
Z37.0 Single live birth
Rationale: The provider notes a past history of anxiety and past abuse of Xanax. “In remission” is not documented. The patient is not currently being treated for anxiety. Codes for these conditions are not reported because they do not meet the definition of a reportable diagnosis.
Effects on infants of drug use during pregnancy, childbirth and the puerperium
Much research has been done on the effects of substance use during and after pregnancy on infants, including tobacco, alcohol and drugs as listed above. One recent government publication provides a good summary of this issue, as follows:
“Research shows that use of tobacco, alcohol, or illicit drugs or misuse of prescription drugs by pregnant women can have severe health consequences for infants. This is because many substances pass easily through the placenta, so substances that a pregnant woman takes also reach the fetus. Recent research shows that smoking tobacco or marijuana, taking prescription pain relievers, or using illegal drugs during pregnancy is associated with double or even triple the risk of stillbirth. Estimates suggest that about 5 percent of pregnant women use one or more addictive substances.
“Regular use of some drugs can cause neonatal abstinence syndrome (NAS), in which the baby goes through withdrawal upon birth. Most research in this area has focused on the effects of opioids (prescription pain relievers or heroin). However, data has shown that use of alcohol, barbiturates, benzodiazepines, and caffeine during pregnancy may also cause the infant to show withdrawal symptoms at birth. The type and severity of an infant’s withdrawal symptoms depend on the drug(s) used, how long and how often the birth mother used, how her body breaks the drug down, and whether the infant was born full term or prematurely.”
New codes added to Chapter 16. Certain Conditions Originating in the Perinatal Period
The new OCG I.C.15.l.3 dovetails nicely with the new codes added to Chapter 16. Certain Conditions Originating in the Perinatal Period.
Ten new codes for newborns affected by maternal drug use were added to code category P04.1 (P04.11 – P04.19) are listed, which includes the drug class. The new codes are an expansion of code subcategory P04.1 Newborn affected by other maternal medication. The new codes enable reporting of specific drug classes antineoplastic chemotherapy, cytotoxic drugs, anticonvulsants, opiates, antidepressants, amphetamines, sedative-hypnotics, anxiolytics and other and unspecified drugs. Note the following when considering reporting and of the new codes from category P04.1-, P04.4- and P04.8-:
- There is documentation that the newborn is affected by one or more of the drug classes listed.
- See and apply the instruction note for this code category to “Code first withdrawal symptoms from maternal use of drugs of addiction, if applicable (P96.1).”
- Recognize the Excludes 2 instruction note, maternal use of drugs of addiction (P04.4-). Report codes from for diagnoses from both category P04.1 and P04.4 when documented.
Two new codes were added to code category P04.4 Newborn affected by maternal use of drugs of addiction:
P04.40 Newborn affected by maternal use of unspecified drugs of addiction
P04.42 Newborn affected by maternal use of hallucinogens
Two new codes were added to code category P04.8 Newborn affected by other maternal noxious substances:
P04.81 Newborn affected by maternal use of cannabis
P04.89 Newborn affected by other maternal noxious substances
Code P96.1 Neonatal withdrawal symptoms from maternal use of drugs of addiction
Code P96.1 Neonatal withdrawal symptoms from maternal use of drugs of addiction includes the diagnoses “drug withdrawal syndrome in infant of dependent mother” and “neonatal abstinence syndrome” (NAS). There is an Excludes 1 note “reactions and intoxications from maternal opiates and tranquilizers administered during labor and delivery (P04.0).”
There are several symptoms of drug withdrawal in a newborn that can develop immediately or up to 14 days after birth, including:
Abnormal sucking reflex
Slow weight gain
Excessive or high-pitched crying
Increased muscle tone
Effects of using some drugs could be long-term and possibly fatal to the baby, including:
Low birth weight
Small head circumference
Sudden infant death syndrome (SIDS)
See the Excludes 1 instruction note in code category P04.1, Excludes 1 dysmorphism due to warfarin (Q86.2), fetal hydantoin syndrome (Q86.1), which are codes and conditions from Chapter 17. Congenital Malformations, Deformations and Chromosomal Abnormalities.
Example 3: Information in a newborn record concerning family history notes that the newborn boy’s mother is just finishing up her chemotherapy treatments for malignant melanoma. She has suffered from and is currently being treated with medication by her obstetrician for depression brought on by her cancer diagnosis. She had been smoking marijuana obtained by her husband to combat the side-effects of the chemotherapy but stopped when she found out that she was pregnant. The infant boy is born vaginally at full-term with birthweight 3,500 grams. Physical examination of body systems on admission and discharge is normal. He is discharged with his mother after two days. The final diagnosis is “full term newborn.”
Report these diagnosis codes:
Z38.00 Single liveborn infant, delivered vaginally
Rationale: There is no documentation that the mother’s chemotherapy or depression medications affected the newborn. There were no symptoms and no treatment was rendered. It would be incorrect to report a P04.11 (antineoplastic), P04.15 (antidepressants) even though his mother is still taking these medications, or P04.81 (cannabis) which she discontinued.
Example 4: A newborn girl is delivered vaginally to a mother enrolled in a methadone maintenance program. The mother is also known to her obstetrician and social services for frequent use of cocaine. The baby girl is delivered prematurely at 35 completed weeks, with a birthweight of 1550 grams. She is fussy and crying. Her mother is discharged after two days but the infant remains in the hospital for a week and receives enteral feedings. She is placed on a treatment protocol for withdrawal from opioids and cocaine. The final diagnosis is “preterm newborn with NAS.”
Report these diagnosis codes in this sequence:
Z38.00 Single liveborn infant, delivered vaginally
P96.1 Neonatal withdrawal symptoms from maternal use of drugs of addiction
P04.14 Newborn affected by maternal use of opiates
P04.41 Newborn affected by maternal use of cocaine
P07.16 Other low birth weight newborn, 1500-1749 grams
P07.38 Preterm newborn, gestational age 35 completed weeks
Rationale: Since this was the birth encounter, a code from Z38 Liveborn infants according to place of birth and type of delivery is always sequenced as the principal diagnosis, in this case Z38.00. The secondary codes are listed with P96.1 sequenced over P04.14 and P04.41 in accordance with the “Code first” instruction note, and P07.16 is sequenced over P07.38 in accordance with the NOTE in code category P07 that instructs sequencing the birth weight before gestational age. It would also be correct to report the secondary codes in this order, as follows: P07.16, P07.38, P96.1, P04.14 and P04.41. This sequencing is also correct because P07.16 is coded over P07.38, and P96.1 is coded over P04.14 and P04.41.
When coding pregnancy, childbirth and the puerperium encounters, keep this in mind:
- A title change and new guideline section was added to OCG I.C.15.l, Alcohol, tobacco and drug use (italicized words added) during pregnancy, childbirth and the puerperium. The title change corresponds to the new official coding guideline (OCG) added to this section that addresses drug use, guideline I.C.15.l.3, Pregnancy, Childbirth, and the Puerperium.
- There were no changes or new codes added to the corresponding code category O99.32- Drug use during pregnancy, childbirth and puerperium.
- A note in code category O99.32- instructs “Use additional code(s) from F11-F16 and F18-F19 to identify manifestations of drug use.”
- When using the additional code(s) from F11-F16 and F18-F19, The OCG’s from Chapter 5. Mental, Behavioral and Neurodevelopmental Disorders must also be applied.
When coding newborn encounters or patients in the perinatal period, keep this in mind:
- Ten new codes for newborns affected by maternal drug use were added to code category P04.1 (P04.11 – P04.19) are listed, which includes the drug class.
- Two new codes were added to code category P04.4 Newborn affected by maternal use of drugs of addiction.
- Two new codes were added to code category P04.8 Newborn affected by other maternal noxious substances.
- These codes are reported only when there is documentation that the newborn is “affected” by one or more of the drugs or substances listed.
- If it is documented that the patient is experiencing withdrawal from maternal use of use of drugs of addiction, sequence the code for withdrawal (P96.1) over the code or codes for the drugs.
- Follow and apply all of the Excludes 1 and Excludes 2 instruction notes that are present in codes and code category P04.1, P04.4, and P96.1.
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