Sample. V18.2 Special Report: Postpartum Readmissions What Drives Your Rate?

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1 V18.2 Special Report: Postpartum Readmissions What Drives Your Rate? INTRODUCTION In FY 2013, the Center for Medicare and Medicaid Services (CMS) began the Hospital Readmission Reduction Program (HRRP) to reduce frequent readmissions for patients with Acute Myocardial Infarction (AMI), Chronic Obstructive Pulmonary Disease (COPD), Heart Failure (HF), Pneumonia, and Coronary Artery Bypass Graft (CABG) Surgery. 1 The Program initiated a reduction in Medicare reimbursement for high readmission hospitals, assuming that a financial penalty would change how hospitals manage at-risk patients prior to and post-discharge. Perinatal readmissions, while not included in HRRP and far less common, have not been without scrutiny. Any maternal or neonatal readmission is a concern. Post-birth separation impacts maternal/infant/family bonding and breastfeeding, and often creates general anxiety for the family. Most providers will look to avoid a readmission for just those reasons. Adding a financial penalty in an attempt to reduce readmissions, however, may assume a level of provider control that is misplaced. Clapp et al 2, recently reported on a retrospective study they conducted using State Inpatient databases from California, Florida and New York to determine the relative effects of patient and hospital factors on maternal postpartum readmissions. The authors recognized that while reimbursement penalties for readmissions have not yet been applied to obstetrics, hospitals with higher readmission rates may be penalized for patient factors outside the control of their health care providers. The goal of the study was to compare the patient, delivery, and hospital characteristics of low readmission hospitals to those of high readmission hospitals. The researchers hypothesized that patient factors, not hospitals factors, would drive higher readmission rates. Patient factors included common comorbidities affecting pregnant women (obesity, hypertension, diabetes, etc.). Hospital characteristics included teaching status (major, minor, nonteaching), profit status (profit, not-for-profit, public) and community status. Community hospitals were defined as short term, non-federal hospitals. Hospitals were also classified by their delivery volume quartile. Readmission rates for each hospital were calculated over the entire period for each state. V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 1

2 Data encompassed the time period from for Florida and New York, and from for California. High readmission hospitals were those in the top quartile for readmissions, and low readmission hospitals were in the bottom quartile. In California, low readmission hospitals had an average rate of 0.75% and high readmission hospitals had an average rate of 1.34%. In Florida, low readmission hospitals had a rate of 1.14% and high readmission hospitals had a rate of 2.00%. In New York, low readmission hospitals had a rate of 0.88% and high readmission hospitals had a rate of 2.26%. Women in low readmission hospitals were more likely to be white, have private insurance, and have higher median incomes. All identified comorbidity rates were higher in the high readmission hospitals, with the most prevalent conditions being pregnancyrelated hypertension and diabetes. There were higher rates of peripartum complication in the high readmission hospitals, with the highest rates being hemorrhage and higher-order lacerations. Cesarean delivery and delivery complications such as operative injury and uterine rupture had a high risk of readmission. In comparison to low readmission hospitals, more patients were cared for at major teaching hospitals in the high readmission group. In this study, perinatal readmissions were more attributable to patient and demographic characteristics than to hospital characteristics. The authors concluded that postpartum readmission metric-based incentives may ultimately penalize hospitals providing high quality care due to patient characteristics specific to their catchment area 3 and largely beyond their immediate control. V18.2 SPEICAL REPORT This Special Report does not attempt to replicate the Clapp study. It is designed to show readmission rates for your hospital compared to the readmission rates of all eight NPIC peer subgroups and the NPIC overall average. The NPIC subgroups reflect differences in academic status and level of care (basic, specialty or subspecialty), and generally track to volume of perinatal discharges. These subgroupings profile hospital characteristics similar to those identified in the Clapp study, so we were curious to see if the differences in maternal readmission rates would be higher for the more complex hospitals and if the profile of patients would indeed reflect more complex patients (at greater risk of readmission). DESCRIPTION OF TABLE The Table accompanying this special report displays your hospital s data in comparison to all NPIC subgroups and the entire NPIC database average. Your subgroup column is highlighted in grey. Section A of the Table shows your total delivery volume, your postpartum readmission rate, the case mix index of all your delivery cases for the period 7/1/2017-6/30/2018, and your adjusted readmission rate. The adjusted readmission rate is calculated by dividing your actual readmission V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 2

3 rate by your case mix index. Your case mix index is a reflection of the acuity of your delivery population, and your adjusted readmission rate neutralizes the impact of your differential acuity and allows for comparison of case mix neutral rates across subgroups. Section B of the Table displays the profile of your delivery population patient characteristics similar to those discussed in the Clapp study: race, payer mix, maternal comorbidities and pregnancy characteristics. All of the ICD-10 codes used to drive the definition of the numerator cases are listed in Appendix A. DISCUSSION The average maternal readmission rates across the eight NPIC subgroups range from 0.65% to 1.37%, compared to the range noted in the Clapp study of 0.75% (low readmission hospitals in CA) and 2.26% (high readmission hospitals in NY). The lower range of rates for the NPIC subgroups may be a reflection of the timing of the analyses ( for the study hospitals vs. 7/2017-6/2018 for the NPIC hospitals). We also speculate that the NPIC member hospitals are somewhat unique in their on-going interest in QI and attention to national trends in issues surrounding perinatal care. The difference in maternal readmission rates across the eight NPIC subgroups seems to follow the pattern identified by Clapp et al. The Academic Regional (AR) subgroup has the highest readmission rate for the period as well as the highest adjusted readmission rate, even though their case mix index is slightly lower than the Academic Specialty (AS) and Georgia (G) subgroups. If we focus our attention on the AR subgroup in comparison to the Newborn Basic (NB) level I subgroup, we note the following: Maternal comorbidity rates are higher in the AR subgroup compared to the NB subgroup for all those listed except for obesity and tobacco use. Pregnancy characteristics of multiple gestation, Preterm labor/delivery and abnormal placentation are notably higher in the AR subgroup compared to the NB subgroup. Prior cesarean delivery rates are comparable for the two subgroups. Overall the non-academic Intermediate (NI) and non-academic Basic (NB) subgroups have lower rates of maternal complications and pregnancy characteristics and lower readmission rates, consistent with the general findings of the study. Questions regarding this Special Report should be directed to Sandra Boyle, Director of Data Services (sboyle@npic.org) or Tara Wilcox, Senior Analyst/ Hospital Liaison (twilcox@npic.org). REFERENCES Clapp M. A, Little, S.E., Zheng, J., Robinson, J. N., Kaimal, J.A. The Relative Effects of Patient and Hospital Characteristics on Perinatal Readmissions, Journal of Perinatology (2018) 38: Clapp, Op. cit. V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 3

4 V18.2 Special Report: Postpartum Readmissions Hospital Subgroup Averages NPIC Database SA1 AR AS NR NS NI NB G CWISH Average A. Postpartum Readmissions Total Deliveries 2,612 3,785 5,388 3,452 2,149 1, ,692 8,716 3,726 Total Postpartum Readmissions within 30 days post-discharge* Postpartum Readmission Rate 1.31% 1.36% 1.12% 1.10% 0.74% 0.81% 0.65% 1.21% 1.22% 1.04% Case Mix Index - All deliveries Case Mix Adjusted Postpartum Readmission Rate 2.75% 2.95% 2.44% 2.49% 1.70% 1.90% 1.51% 2.59% 2.72% 2.31% B. Delivery Patient Characteristics (% of total deliveries) B1. Race White 55.0% 54.7% 59.6% 61.7% 61.3% 69.4% 65.3% 33.2% 40.5% 55.9% Black 41.5% 20.1% 19.9% 16.9% 17.0% 8.7% 15.9% 55.1% 14.9% 19.5% Asian 0.0% 5.7% 4.9% 3.9% 5.1% 6.4% 5.1% 1.2% 9.9% 5.6% Native American 0.2% 0.8% 0.2% 1.0% 0.3% 2.1% 0.7% 0.1% 0.2% 0.7% Other 0.0% 1.7% 2.2% 1.8% 2.4% 1.9% 2.5% 3.5% 8.7% 3.2% Unknown/Missing 3.3% 17.2% 13.2% 14.7% 13.9% 11.6% 10.6% 7.0% 25.7% 15.1% B2. Payer mix Private 53.0% 60.2% 56.9% 52.7% 56.5% 64.0% 49.8% 32.0% 63.1% 56.1% Public 46.8% 31.7% 34.6% 41.1% 40.0% 34.1% 48.4% 62.9% 31.7% 38.8% Uninsured/self pay 0.3% 0.6% 1.9% 3.1% 2.7% 1.4% 1.6% 3.4% 2.4% 2.1% Other 0.0% 7.1% 6.1% 2.8% 0.8% 0.3% 0.2% 0.4% 1.7% 2.5% Unknown/Missing 0.0% 0.3% 0.5% 0.3% 0.1% 0.3% 0.0% 1.2% 1.1% 0.5% B3. Maternal comorbidities Obesity 25.3% 14.9% 15.8% 12.6% 7.9% 8.3% 15.9% 14.3% 11.2% 12.0% Hypertensive disorder 4.2% 4.2% 3.5% 2.6% 2.4% 2.1% 2.8% 7.2% 3.0% 3.3% Pregnancy related hypertensive disorder 14.6% 16.0% 14.3% 10.9% 9.4% 10.4% 11.2% 15.7% 12.0% 12.3% Diabetes 10.5% 10.5% 9.5% 8.4% 9.3% 7.3% 8.7% 9.0% 10.1% 9.2% Asthma 9.7% 8.3% 8.7% 5.6% 5.1% 5.4% 6.5% 7.2% 6.5% 6.5% Tobacco Use 6.4% 4.2% 3.6% 5.1% 4.2% 5.3% 6.9% 6.2% 3.3% 4.6% Thyroid disease 8.9% 8.1% 7.1% 5.9% 5.5% 5.2% 5.5% 4.6% 7.1% 6.2% Psychiatric disease 6.4% 9.5% 8.2% 6.1% 5.6% 6.9% 8.0% 7.7% 7.3% 7.3% Seizure disorder 2.3% 2.3% 2.1% 1.3% 1.1% 1.3% 1.6% 2.5% 2.4% 1.8% B4. Pregnancy characteristics Multiple gestation 2.8% 2.8% 2.3% 1.8% 1.5% 1.0% 1.0% 2.9% 2.2% 1.9% Prior cesarean delivery 19.0% 17.6% 19.6% 19.1% 19.1% 16.6% 17.8% 19.5% 18.2% 18.3% Preterm labor/delivery 12.2% 8.9% 7.2% 6.9% 6.0% 4.3% 4.7% 11.7% 6.8% 7.0% Abnormal placentation 2.1% 2.6% 1.9% 1.7% 1.7% 1.4% 1.4% 2.5% 2.0% 1.9% * Total deliveries discharged to home (with or without home health) and readmitted within 30 days Date Range of Hospital Data: 7/1/2017-6/30/2018 Subgroup: AR - Academic Regional Date Range of Comparison Data: 7/1/2017-6/30/2018 NPIC.ORG 4

5 Obesity O Obesity complicating pregnancy, unspecified trimester O Obesity complicating pregnancy, first trimester O Obesity complicating pregnancy, second trimester O Obesity complicating pregnancy, third trimester O Obesity complicating childbirth O Obesity complicating the puerperium Z68.30 Body mass index (BMI) , adult Z68.31 Body mass index (BMI) , adult Z68.32 Body mass index (BMI) , adult Z68.33 Body mass index (BMI) , adult Z68.34 Body mass index (BMI) , adult Z68.35 Body mass index (BMI) , adult Z68.36 Body mass index (BMI) , adult Z68.37 Body mass index (BMI) , adult Z68.38 Body mass index (BMI) , adult Z68.39 Body mass index (BMI) , adult Z68.41 Body mass index (BMI) , adult Z68.42 Body mass index (BMI) , adult Z68.43 Body mass index (BMI) , adult Z68.44 Body mass index (BMI) , adult Z68.45 Body mass index (BMI) 70 or greater, adult Hypertensive Disorder O10 Pre existing hypertension complicating pregnancy, childbirth, and the puerperium O Pre existing essential hypertension complicating pregnancy, first trimester O Pre existing essential hypertension complicating pregnancy, second trimester O Pre existing essential hypertension complicating pregnancy, third trimester O Pre existing essential hypertension complicating pregnancy, unspecified trimester O10.02 Pre existing essential hypertension complicating childbirth O10.03 Pre existing essential hypertension complicating the puerperium O Pre existing hypertensive heart disease complicating pregnancy, first trimester O Pre existing hypertensive heart disease complicating pregnancy, second trimester O Pre existing hypertensive heart disease complicating pregnancy, third trimester O Pre existing hypertensive heart disease complicating pregnancy, unspecified trimester O10.12 Pre existing hypertensive heart disease complicating childbirth O10.13 Pre existing hypertensive heart disease complicating the puerperium O Pre existing hypertensive chronic kidney disease complicating pregnancy, first trimester O Pre existing hypertensive chronic kidney disease complicating pregnacy, second trimester O Pre existing hypertensive chronic kidney disease complicating pregnancy, third trimester O Pre existing hypertensive chronic kidney disease complicating pregnancy, unspecified trimester O10.22 Pre existing hypertensive chronic kidney disease complicating childbirth O10.23 Pre existing hypertensive chronic kidney disease complicating the puerperium O Pre existing hypertensive heart and chronic kidney disease complicating pregnancy, first trimester O Pre existing hypertensive heart and chronic kidney disease complicating pregnancy, second trimester V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 5

6 Hypertensive Disorder (con.'t) O Pre existing hypertensive heart and chronic kidney disease complicating pregnancy, third trimester O Pre existing hypertensive heart and chronic kidney disease complicating pregnancy, unspecified trimester O10.32 Pre existing hypertensive heart and chronic kidney disease complicating childbirth O10.33 Pre existing hypertensive heart and chronic kidney disease complicating the puerperium O Pre existing secondary hypertension complicating pregnancy, first trimester O Pre existing secondary hypertension complicating pregnancy, second trimester O Pre existing secondary hypertension complicating pregnancy, third trimester O Pre existing secondary hypertension complicating pregnancy, unspecified trimester O10.42 Pre existing secondary hypertension complicating childbirth O10.43 Pre existing secondary hypertension complicating the puerperium O Unspecified pre existing hypertension complicating pregnancy, first trimester O Unspecified pre existing hypertension complicating pregnancy, second trimester O Unspecified pre existing hypertension complicating pregnancy, third trimester O Unspecified pre existing hypertension complicating pregnancy, unspecified trimester O10.92 Unspecified pre existing hypertension complicating childbirth O10.93 Unspecified pre existing hypertension complicating the puerperium O11 Pre existing hypertension with pre eclampsia O11.1 Pre existing hypertension with pre eclampsia, first trimester O11.2 Pre existing hypertension with pre eclampsia, second trimester O11.3 Pre existing hypertension with pre eclampsia, third trimester O11.4 Pre existing hypertension with pre eclampsia, complicating childbirth O11.5 Pre existing hypertension with pre eclampsia, complicating the puerperium O11.9 Pre existing hypertension with pre eclampsia, unspecified trimester Pregnancy Related Hypertensive Disorder O13 Gestational [pregnancy induced] hypertension without significant proteinuria O13.1 Gestational hypertension w/o significant proteinuria, first trimester O13.2 Gestational hypertension w/o significant proteinuria, second trimester O13.3 Gestational hypertension w/o significant proteinuria, third trimester O13.4 Gestational [pregnancy induced] hypertension without significant proteinuria, complicating child birth. O13.5 Gestational (pregnancy induced) hypertension without significant proteinuria, complicating the puerperium O13.9 Gestational [pregnancy induced] hypertension without significant proteinuria, unspecified trimester O14 Pre eclampsia O14.00 Mild to moderate pre eclampsia, unspecifed trimester O14.02 Mild to moderate pre eclampsia, second trimester O14.03 Mild to moderate pre eclampsia, third trimester O14.04 Mild to moderate pre eclampsia, complicating childbirth O14.05 Mild to moderate pre eclampsia, complicating the puerperium O14.10 Severe pre eclampsia, unspecified trimester O14.12 Severe pre eclampsia, second trimester O14.13 Severe pre eclampsia, third trimester O14.14 Severe pre eclampsia complicating childbirth O14.15 Severe pre eclampsia, complicating the puerperium O14.20 HELLP syndrome (HELLP), unspecified trimester V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 6

7 Pregnancy Related Hypertensive Disorder (con.'t) O14.22 HELLP syndrome (HELLP), second trimester O14.23 HELLP syndrome (HELLP), third trimester O14.24 HELLP syndrome, complicating childbirth O14.25 HELLP syndrome, complicating the puerperium O14.90 Unspecified pre eclampsia, unspecified trimester O14.92 Unspecified pre eclampsia, second trimester O14.93 Unspecified pre eclampsia, third trimester O14.94 Unspecified pre eclampsia, complicating childbirth O14.95 Unspecified pre eclampsia, complicating the puerperium O15 Eclampsia O15.00 Eclampsia in pregnancy, unspecified trimester O15.02 Eclampsia in pregnancy, second trimester O15.03 Eclampsia in pregnancy, third trimester O15.1 Eclampsia in labor O15.2 Eclampsia in the puerperium O15.9 Eclampsia, unspecified as to time period O16 Unspecified maternal hypertension O16.1 Unspecified maternal hypertension, first trimester O16.2 Unspecified maternal hypertension, second trimester O16.3 Unspecified maternal hypertension, third trimester O16.4 Unspecified maternal hypertension, complicating childbirth O16.5 Unspecified maternal hypertension, complicating the puerperium O16.9 Unspecified maternal hypertension, unspecified trimester Diabetes ( includes gestational) E10 Type 1 diabetes mellitus E10.10 Type 1 diabetes mellitus with ketoacidosis without coma E10.11 Type 1 diabetes mellitus with ketoacidosis with coma E10.21 Type 1 diabetes mellitus with diabetic nephropathy E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease E10.29 Type 1 diabetes mellitus with other diabetic kidney complication E Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema E Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema E Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula E Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula E Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment E Type 1 diabetes mellitus with stable proliferative diabetic retinopathy V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 7

8 Diabetes ( includes gestational) (con.'t) E Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema E10.36 Type 1 diabetes mellitus with diabetic cataract E10.37 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment E10.39 Type 1 diabetes w oth diabetic ophthalmic complication E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy E10.44 Type 1 diabetes mellitus with diabetic amyotrophy E10.49 Type 1 diabetes mellitus with other diabetic neurological complication E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.59 Type 1 diabetes mellitus with other circulatory complications E Type 1 diabetes mellitus with diabetic neuropathic arthropathy E Type 1 diabetes mellitus with other diabetic arthropathy E Type 1 diabetes mellitus with diabetic dermatitis E Type 1 diabetes mellitus with foot ulcer E Type 1 diabetes mellitus with other skin ulcer E Type 1 diabetes mellitus with other skin complications E Type 1 diabetes mellitus with periodontal disease E Type 1 diabetes mellitus with other oral complications E Type 1 diabetes mellitus with hypoglycemia with coma E Type 1 diabetes mellitus with hypoglycemia without coma E10.65 Type 1 diabetes mellitus with hyperglycemia E10.69 Type 1 diabetes mellitus with other specified complication E10.8 Type 1 diabetes mellitus with unspecified complications E10.9 Type 1 diabetes mellitus without complications E11 Type 2 diabetes mellitus E11.00 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic hyperosmolar coma (NKHHC) E11.01 Type 2 diabetes mellitus with hyperosmolarity with coma E11.10 Type 2 diabetes mellitus with ketoacidosis without coma E11.11 Type 2 diabetes mellitus with ketoacidosis with coma E11.21 Type 2 diabetes mellitus with diabetic nephropathy E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease E11.29 Type 2 diabetes mellitus with other diabetic kidney complication E Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema E Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 8

9 Diabetes ( includes gestational) (con.'t) E Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula E Type 2 diabetes mellitus with prolifera ve diabe c re nopathy with trac on re nal detachment not involving the macula E Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment E Type 2 diabetes mellitus with stable proliferative diabetic retinopathy E Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema E11.36 Type 2 diabetes mellitus with diabetic cataract E11.37 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy E11.44 Type 2 diabetes mellitus with diabetic amyotrophy E11.49 Type 2 diabetes mellitus with other diabetic neurological complication E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene E11.59 Type 2 diabetes mellitus with other circulatory complications E Type 2 diabetes mellitus with diabetic neuropathic arthropathy E Type 2 diabetes mellitus with other diabetic arthropathy E Type 2 diabetes mellitus with diabetic dermatitis E Type 2 diabetes mellitus with foot ulcer E Type 2 diabetes mellitus with other skin ulcer E Type 2 diabetes mellitus with other skin complications E Type 2 diabetes mellitus with periodontal disease E Type 2 diabetes mellitus with other oral complications E Type 2 diabetes mellitus with hypoglycemia with coma E Type 2 diabetes mellitus with hypoglycemia without coma E11.65 Type 2 diabetes mellitus with hyperglycemia E11.69 Type 2 diabetes mellitus with other specified complication E11.8 Type 2 diabetes mellitus with unspecified complications E11.9 Type 2 diabetes mellitus without complications E13 Other specified diabetes mellitus E13.00 Other specified diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic hyperosmolar coma (NKHHC) E13.01 Other specified diabetes mellitus with hyperosmolarity with coma E13.10 Other specified diabetes mellitus with ketoacidosis without coma E13.11 Other specified diabetes mellitus with ketoacidosis with coma E13.21 Other specified diabetes mellitus with diabetic nephropathy E13.22 Other specified diabetes mellitus with diabetic chronic kidney disease E13.29 Other specified diabetes mellitus with other diabetic kidney complication E Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema E Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema E Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 9

10 Diabetes ( includes gestational) (con.'t) E Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema E Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula E Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula E Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment E Other specified diabetes mellitus with stable proliferative diabetic retinopathy E Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema E13.36 Other specified diabetes mellitus with diabetic cataract E13.37 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment E13.39 Other specified diabetes mellitus with other diabetic ophthalmic complication E13.40 Other specified diabetes mellitus with diabetic neuropathy, unspecified E13.41 Other specified diabetes mellitus with diabetic mononeuropathy E13.42 Other specified diabetes mellitus with diabetic polyneuropathy E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy E13.44 Other specified diabetes mellitus with diabetic amyotrophy E13.49 Other specified diabetes mellitus with other diabetic neurological complication E13.51 Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene E13.59 Other specified diabetes mellitus with other circulatory complications E Other specified diabetes mellitus with diabetic neuropathic arthropathy E Other specified diabetes mellitus with other diabetic arthropathy E Other specified diabetes mellitus with diabetic dermatitis E Other specified diabetes mellitus with foot ulcer E Other specified diabetes mellitus with other skin ulcer E Other specified diabetes mellitus with other skin complications E Other specified diabetes mellitus with periodontal disease E Other specified diabetes mellitus with other oral complications E Other specified diabetes mellitus with hypoglycemia with coma E Other specified diabetes mellitus with hypoglycemia without coma E13.65 Other specified diabetes mellitus with hyperglycemia E13.69 Other specified diabetes mellitus with other specified complication E13.8 Other specified diabetes mellitus with unspecified complications E13.9 Other specified diabetes mellitus without complications O24 Diabetes mellitus in pregnancy, childbirth, and the puerperium O24.01 Pre existing type 1 diabetes mellitus, in pregnancy O Pre existing type 1 diabetes mellitus, in pregnancy, first trimester O Pre existing type 1 diabetes mellitus, in pregnancy, second trimester O Pre existing type 1 diabetes mellitus, in pregnancy, third trimester O Pre existing type 1 diabetes mellitus, in pregnancy, unspecified trimester O24.02 Pre existing type 1 diabetes mellitus, in childbirth O24.03 Pre existing type 1 diabetes mellitus, in the puerperium O Pre existing type 2 diabetes mellitus, in pregnancy, first trimester V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 10

11 Diabetes ( includes gestational) (con.'t) O Pre existing type 2 diabetes mellitus, in pregnancy, second trimester O Pre existing type 2 diabetes mellitus, in pregnancy, third trimester O Pre existing type 2 diabetes mellitus, in pregnancy, unspecified trimester O24.12 Pre existing type 2 diabetes mellitus, in childbirth O24.13 Pre existing type 2 diabetes mellitus, in the puerperium O24.31 Unspecified pre existing diabetes mellitus in pregnancy O Unspecified pre existing diabetes mellitus in pregnancy, first trimester O Unspecified pre existing diabetes mellitus in pregnancy, second trimester O Unspecified pre existing diabetes mellitus in pregnancy, third trimester O Unspecified pre existing diabetes mellitus in pregnancy, unspecified trimester O24.32 Unspecified pre existing diabetes mellitus in childbirth O24.33 Unspecified pre existing diabetes mellitus in the puerperium O Gestational diabetes mellitus in pregnancy, diet controlled O Gestational diabetes mellitus in pregnancy, insulin controlled O Gestational diabetes mellitus in pregnancy, controlled by oral hypoglycemic drugs O Gestational diabetes mellitus in pregnancy, unspecified control O Gestational diabetes mellitus in childbirth, diet controlled O Gestational diabetes mellitus in childbirth, insulin controlled O Gestational diabetes mellitus in childbirth, controlled by oral hypoglycemic drugs O Gestational diabetes mellitus in childbirth, unspecified control O Gestational diabetes mellitus in the peurperium, diet controlled O Gestational diabetes mellitus in the peurperium, insulin controlled O Gestational diabetes mellitus in the puerperium, controlled by oral hypoglycemic drugs O Gestational diabetes mellitus in the puerperium, unspecified control O Other pre existing diabetes mellitus in pregnancy, first trimester O Other pre existing diabetes mellitus in pregnancy, second trimester O Other pre existing diabetes mellitus in pregnancy, third trimester O Other pre existing diabetes mellitus in pregnancy, unspecified trimester O24.82 Other pre existing diabetes mellitus in childbirth O24.83 Other pre existing diabetes mellitus in the puerperium O Unspecified diabetes mellitus in pregnancy, first trimester O Unspecified diabetes mellitus in pregnancy, second trimester O Unspecified diabetes mellitus in pregnancy, third trimester O Unspecified diabetes mellitus in pregnancy, unspecified trimester O24.92 Unspecified diabetes mellitus in childbirth O24.93 Unspecified diabetes mellitus in the puerperium O Abnormal glucose complicating pregnancy O Abnormal glucose complicating childbirth O Abnormal glucose complicating the puerperium V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 11

12 Asthma O Diseases of the respiratory system complicating pregnancy, first trimester O Diseases of the respiratory system complicating pregnancy, second trimester O Diseases of the respiratory system complicating pregnancy, third trimester O Diseases of the respiratory system complicating pregnancy, unspecified trimester O99.52 Diseases of the respiratory system complicating childbirth O99.53 Diseases of the respiratory system complicating the puerperium J45 Asthma J45.20 Mild intermittent asthma, uncomplicated J45.21 Mild intermittent asthma with (acute) exacerbation J45.22 Mild intermittent asthma with status asthmaticus J45.30 Mild persistent asthma, uncomplicated J45.31 Mild persistent asthma with (acute) exacerbation J45.32 Mild persistent asthma with status asthmaticus J45.40 Moderate persistent asthma, uncomplicated J45.41 Moderate persistent asthma with (acute) exacerbation J45.42 Moderate persistent asthma with status asthmaticus J45.50 Severe persistent asthma, uncomplicated J45.51 Severe persistent asthma with (acute) exacerbation J45.52 Severe persistent asthma with status asthmaticus J Unspecified asthma with (acute) exacerbation J Unspecified asthma with status asthmaticus J Unspecified asthma, uncomplicated J Exercise induced bronchospasm J Cough variant asthma J Other asthma Tobacco Use O Smoking (tobacco) complicating pregnancy, unspecified trimester O Smoking (tobacco) complicating pregnancy, first trimester O Smoking (tobacco) complicating pregnancy, second trimester O Smoking (tobacco) complicating pregnancy, third trimester O Smoking (tobacco) complicating childbirth O Smoking (tobacco) complicating the puerperium Thyroid Disease O90.5 Postpartum thyroiditis O Endocrine, nutritional and metabolic diseases complicating pregnancy, unspecified trimester O Endocrine, nutritional and metabolic diseases complicating pregnancy, first trimester O Endocrine, nutritional and metabolic diseases complicating pregnancy, second trimester O Endocrine, nutritional and metabolic diseases complicating pregnancy, third trimester O Endocrine, nutritional and metabolic diseases complicating childbirth O Endocrine, nutritional and metabolic diseases complicating the puerperium Psychiatric Disease O Other mental disorders complicating pregnancy, unsp trimester O Other mental disorders complicating pregnancy, first trimester V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 12

13 Psychiatric Disease (con.'t) O Other mental disorders comp pregnancy, second trimester O Other mental disorders complicating pregnancy, third trimester O Other mental disorders complicating childbirth O Other mental disorders complicating the puerperium F53 Mental and behavioral disorders associated with the puerperium, not elsewhere classified Seizure Disorder O Diseases of the nervous system complicating pregnancy, unspecified trimester O Diseases of the nervous system complicating pregnancy, first trimester O Diseases of the nervous system complicating pregnancy, second trimester O Diseases of the nervous system complicating pregnancy, third trimester O Diseases of the nervous system complicating childbirth O Diseases of the nervous system complicating the puerperium V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 13

14 Pregnancy Characteristics Multiple Gestation Z37.2 Twins, both inborn Z37.3 Twins, one liveborn and one stillborn Z37.4 Twins, both stillborn Z37.50 Multiple births, unspecified, all liveborn Z37.51 Triplets, all liveborn Z37.52 Quadruplets, all liveborn Z37.53 Quintuplets, all liveborn Z37.54 Sextuplets, all liveborn Z37.59 Other multiple births, all liveborn Z37.60 Multiple births, unspecified, some liveborn Z37.61 Triplets, some liveborn Z37.62 Quadruplets, some liveborn Z37.63 Quintuplets, some liveborn Z37.64 Sextuplets, some liveborn Z37.69 Other multiple births, some liveborn Z37.7 Other multiple births, all stillborn Prior Cesarean Delivery O Maternal care for low transverse scar from previous cesarean delivery O Maternal care for vertical scar from previous cesarean delivery O Maternal care for unspecified type scar from previous cesarean delivery Preterm Delivery/Labor O Preterm premature rupture of membranes, onset of labor within 24 hours of rupture, first trimester O Preterm premature rupture of membranes, onset of labor within 24 hours of rupture, second trimester O Preterm premature rupture of membranes, onset of labor within 24 hours of rupture, third trimester O Preterm premature rupture of membranes, onset of labor within 24 hours of rupture, unspecified trimester O Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, first trimester O Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, second trimester O Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, third trimester O Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, unspecified trimeste O first trimester O second trimester O third trimester O unspecified trimester O60.10 Preterm labor with preterm delivery, unspecified trimester O60.12 Preterm labor second trimester with preterm delivery second trimester O60.13 Preterm labor second trimester with preterm delivery third trimester O60.14 Preterm labor third trimester with preterm delivery third trimester Abnormal Placentation O44 Placenta previa O44.00 Complete placenta previa NOS or without hemorrhage, unspecified trimester O44.01 Complete placenta previa NOS or without hemorrhage, first trimester O44.02 Complete placenta previa NOS or without hemorrhage, second trimester O44.03 Complete placenta previa NOS or without hemorrhage, third trimester V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 14

15 Pregnancy Characteristics Abnormal Placentation (con.'t) O44.10 Complete placenta previa with hemorrhage, unspecified trimester O44.11 Complete placenta previa with hemorrhage, first trimester O44.12 Complete placenta previa with hemorrhage, second trimester O44.13 Complete placenta previa with hemorrhage, third trimester O44.20 Partial placenta previa NOS or without hemorrhage, unspecified trimester O44.21 Partial placenta previa NOS or without hemorrhage, first trimester O44.22 Partial placenta previa NOS or without hemorrhage, second trimester O44.23 Partial placenta previa NOS or without hemorrhage, third trimester O44.30 Partial placenta previa with hemorrhage, unspecified trimester O44.31 Partial placenta previa with hemorrhage, first trimester O44.32 Partial placenta previa with hemorrhage, second trimester O44.33 Partial placenta previa with hemorrhage, third trimester O44.40 Low lying placenta NOS or without hemorrhage, unspecified trimester O44.41 Low lying placenta NOS or without hemorrhage, first trimester O44.42 Low lying placenta NOS or without hemorrhage, second trimester O44.43 Low lying placenta NOS or without hemorrhage, third trimester O44.50 Low lying placenta with hemorrhage, unspecified trimester O44.51 Low lying placenta with hemorrhage, first trimester O44.52 Low lying placenta with hemorrhage, second trimester O44.53 Low lying placenta with hemorrhage, third trimester O45 Premature separation of placenta [abruption placentae] O Premature separation of placenta with coagulation defect, unspecified, first trimester O Premature separation of placenta with coagulation defect, unspecified, second trimester O Premature separation of placenta with coagulation defect, unspecified, third trimester O Premature separation of placenta with coagulation defect, unspecified, unspecified trimester O Premature separation of placenta with afibrinogenemia, first trimester O Premature separation of placenta with afibrinogenemia, second trimester O Premature separation of placenta with afibrinogenemia, third trimester O Premature separation of placenta with afibrinogenemia, unspecified trimester O Premature separation of placenta with disseminated intravascular coagulation, first trimester O Premature separation of placenta with disseminated intravascular coagulation, second trimester O Premature separation of placenta with disseminated intravascular coagulation, third trimester O Premature separation of placenta with disseminated intravascular coagulation, unspecified trimester O Premature separation of placenta with other coagulation defect, first trimester O Premature separation of placenta with other coagulation defect, second trimester O Premature separation of placenta with other coagulation defect, third trimester O Premature separation of placenta with other coagulation defect, unspecified trimester O45.8X1 Other premature separation of placenta, first trimester O45.8X2 Other premature separation of placenta, second trimester O45.8X3 Other premature separation of placenta, third trimester O45.8X9 Other premature separation of placenta, unspecified trimester O45.90 Premature separation of placenta, unspecified, unspecified trimester O45.91 Premature separation of placenta, unspecified, first trimester O45.92 Premature separation of placenta, unspecified, second trimester V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 15

16 Pregnancy Characteristics Abnormal Placentation (con.'t) O45.93 Premature separation of placenta, unspecified, third trimester O Placenta accreta, first trimester O Placenta accreta, second trimester O Placenta accreta, third trimester O Placenta accreta, unspecified trimester O Placenta increta, first trimester O Placenta increta, second trimester O Placenta increta, third trimester O Placenta increta, unspecified trimester O Placenta percreta, first trimester O Placenta percreta, second trimester O Placenta percreta, third trimester O Placenta percreta, unspecified trimester O69.4 Labor and delivery complicated by vasa previa V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 16

17 Payer Mix Definitions Public: Medicare Medicaid Champus/Tricare HMO/Medicaid Other Government Private: Other: Uninsured/ Self pay: Unknown/ Missing: Blue Cross Commercial Insurance HMO Worker's Comp Other Self Free Care Unknown/Missing V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 17