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
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
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, Eclampsia, sepsis,
hysterectomy,
pulmonary
ventilation, etc.
embolism, etc.
CDC
Academic Institutions / Major
Medical Professional
Organizations
Public Health State
Departments
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)
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
ICD-9-CM Issue: Diagnosis Code 669.4
• 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
DX
669.4x, 997.1
• Cerebral anoxia following cesarean or other
obstetrical surgery or procedure, including
delivery NOS
Drop 669.4x and corresponding ICD-10I97.120, I97.121, I97.130,
CM=O75.4 based on the validation studies
I97.131
(MGH/UMH, CDC), prevalence/use data from
states (unreasonably high)and mortality data
(unreasonably low) from the 1994-2013 NIS.
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
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),
2. 60-70% 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).
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).
Blood transfusions
• 99.0x  160 ICD-10-PCS codes
With 6th “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
30233
30240
30243
Peripheral vein,
percutaneous
Central vein, open
approach
Central vein,
percutaneous
approach
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
Why Are There So Many Diagnosis
Codes?
• Greater specificity and detail
in all diagnosis codes
• 34,250 (50%) of all ICD-10CM codes are related to the
musculoskeletal system
• 17,045 (25%) of all ICD-10CM codes are related to
fractures
• 10,582 (62%) of fracture
codes to distinguish ‘right’
vs. ‘left’
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Injuries
Exclude due to small # and limited # interventions among OB/GYN
Complication
Intracranial injuries
Delivery
hospitalizations In-hospital mortality among
with complications
delivery
hospitalizations
with complications
Weighted N Rate per 10,000 Weighted N Percent and
delivery
Standard
hospitalizations
Errors
and
Standard
Errors
1173
0.14 (0.01)
199
17.00 (2.61)
Internal injuries of 5716
thorax,
abdomen,
and pelvis
0.70 (0.03)
306
5.36 (0.64)
Steps (opportunities for miscommunication) in
recording/interpretation of administrative records
Clinician
Coder
•Diagnosis: Training, institutional practice
•Currently used classification/guidelines: Training, institutional
practice, ambiguity
•Recording (quality): Varies widely, sometime without DXs,
notes only
• Interpretation: Training, institutional practice, facilityapproved abbreviation list
• Currently used classification / definitions: ICD-9-CM/ICD-10CM, 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
Steps (opportunities for miscommunication) in
recording/interpretation of administrative records
Clinician
Coder
•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))
•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
Where we are?
• Crossing the bridge, preparing
for ICD-10-CM
• Revising indicators based on 20year nation wide in-hospital
mortality data
• Developing surveillance for nonsevere maternal morbidity
• Pilot registry or more advanced
surveillance system
email: ekuklina@cdc.gov