Laura Meints

Prospective study of coding practices for cesarean deliveries

OBJECTIVE: To assess consistency of hospital coding for patients with cesarean delivery-related admissions. METHODS: Hospital coders from 11 participating institutions received a brief questionnaire and a standardized, inpatient record that was developed for nine hypothetical patients who delivered by cesarean delivery. They were asked to assign a diagnosis-related group (DRG) for each case and to submit the DRG, assigned International Classification of Diseases, 9th Revision (ICD-9) codes, and any relevant Physicians’ Current Procedural Terminology Coding System codes used in their coding for each case. These responses were analyzed by mean analysis and analysis of variance tests to evaluate variation in coding practices submitted. RESULTS: Each participating academic hospital has a level III nursery, takes maternal transports, and has a residency and maternal–fetal medicine staff. Consensus in DRG coding was found in only two thirds of cases. Variation in use of ICD-9 codes existed, with 13.7% of ICD-9 codes assigned by all of the coding departments and 24.2% of ICD-9 codes uniquely used by a single institution. Variation in use of Physicians’ Current Procedural Terminology Coding System codes also occurred, with 16.3% of the procedure codes used in the same case by all institutions and 28.6% used by a single institution. CONCLUSION: Documenting providers, coders, and institutions should exercise caution in the use of DRG codes, procedure codes, and ICD-9 codes for cesarean deliveries. The variability noted reflects the difficulty of the coding process and judgments that need to be made by the coders in assigning the codes. LEVEL OF EVIDENCE: III

Evidence to inform decisions about maternal-fetal surgery: technical brief.

OBJECTIVE: To summarize the state of research in maternal–fetal surgery regarding the surgical repair of abnormalities in fetuses in the womb. DATA SOURCES: We searched MEDLINE from 1980 to 2010 for studies of maternal–fetal surgery for the following conditions: twin–twin transfusion syndrome, obstructive uropathy, congenital diaphragmatic hernia, myelomeningocele, thoracic lesions, cardiac malformations, and sacrococcygeal teratoma. METHODS OF STUDY SELECTION: We used pilot-tested data collection forms to screen publications for inclusion and to extract data. We compiled information about how fetal diagnoses were defined, maternal inclusion criteria, type of surgery, study design, country, setting, comparators used, length of follow-up, outcomes measured, and adverse events. TABULATION, INTEGRATION, AND RESULTS: Two reviewers independently extracted data and discordance was resolved by a third party. Of 1,341 articles located, we retained 258 (comprising 166 unique study populations). Three studies were randomized controlled trials; the majority of the evidence was observational (116 case series [70%], 36 retrospective [22%], and 11 prospective [7%] cohorts). Twin–twin transfusion is the most studied condition, with 84 studies including 2,532 pregnancies. Fewer than 500 pregnancies are represented in the literature for each of the other conditions except congenital diaphragmatic hernia (n=503). Inclusion criteria were poorly specified. Outcomes typically measured were survival to birth, preterm birth, and neonatal death. Longer-term outcomes were sparse but included pulmonary, renal, and neurologic status and developmental milestones. Maternal outcome data were rare. CONCLUSION: Although developing rapidly, maternal–fetal surgery research has yet to achieve the typical quality of studies and aggregate strength of evidence needed to optimally inform care.