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

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

Data encompassed the time period from 2004-2013 for Florida and New York, and from 2004-2011 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

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 (2004-2013 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 1 https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html 2 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) 38:804 812 3 Clapp, Op. cit. V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 3

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 1,949 769 2,692 8,716 3,726 Total Postpartum Readmissions within 30 days post-discharge* 34 52 55 40 16 19 5 36 102 42 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 0.4771 0.4605 0.4638 0.4424 0.4356 0.4275 0.4335 0.4714 0.4488 0.4467 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

Obesity O99.210 Obesity complicating pregnancy, unspecified trimester O99.211 Obesity complicating pregnancy, first trimester O99.212 Obesity complicating pregnancy, second trimester O99.213 Obesity complicating pregnancy, third trimester O99.214 Obesity complicating childbirth O99.215 Obesity complicating the puerperium Z68.30 Body mass index (BMI) 30.0 30.9, adult Z68.31 Body mass index (BMI) 31.0 31.9, adult Z68.32 Body mass index (BMI) 32.0 32.9, adult Z68.33 Body mass index (BMI) 33.0 33.9, adult Z68.34 Body mass index (BMI) 34.0 34.9, adult Z68.35 Body mass index (BMI) 35.0 35.9, adult Z68.36 Body mass index (BMI) 36.0 36.9, adult Z68.37 Body mass index (BMI) 37.0 37.9, adult Z68.38 Body mass index (BMI) 38.0 38.9, adult Z68.39 Body mass index (BMI) 39.0 39.9, adult Z68.41 Body mass index (BMI) 40.0 44.9, adult Z68.42 Body mass index (BMI) 45.0 49.9, adult Z68.43 Body mass index (BMI) 50 59.9, adult Z68.44 Body mass index (BMI) 60.0 69.9, adult Z68.45 Body mass index (BMI) 70 or greater, adult Hypertensive Disorder O10 Pre existing hypertension complicating pregnancy, childbirth, and the puerperium O10.011 Pre existing essential hypertension complicating pregnancy, first trimester O10.012 Pre existing essential hypertension complicating pregnancy, second trimester O10.013 Pre existing essential hypertension complicating pregnancy, third trimester O10.019 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 O10.111 Pre existing hypertensive heart disease complicating pregnancy, first trimester O10.112 Pre existing hypertensive heart disease complicating pregnancy, second trimester O10.113 Pre existing hypertensive heart disease complicating pregnancy, third trimester O10.119 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 O10.211 Pre existing hypertensive chronic kidney disease complicating pregnancy, first trimester O10.212 Pre existing hypertensive chronic kidney disease complicating pregnacy, second trimester O10.213 Pre existing hypertensive chronic kidney disease complicating pregnancy, third trimester O10.219 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 O10.311 Pre existing hypertensive heart and chronic kidney disease complicating pregnancy, first trimester O10.312 Pre existing hypertensive heart and chronic kidney disease complicating pregnancy, second trimester V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 5

Hypertensive Disorder (con.'t) O10.313 Pre existing hypertensive heart and chronic kidney disease complicating pregnancy, third trimester O10.319 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 O10.411 Pre existing secondary hypertension complicating pregnancy, first trimester O10.412 Pre existing secondary hypertension complicating pregnancy, second trimester O10.413 Pre existing secondary hypertension complicating pregnancy, third trimester O10.419 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 O10.911 Unspecified pre existing hypertension complicating pregnancy, first trimester O10.912 Unspecified pre existing hypertension complicating pregnancy, second trimester O10.913 Unspecified pre existing hypertension complicating pregnancy, third trimester O10.919 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

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 E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema E10.321 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E10.329 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E10.331 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E10.339 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E10.341 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E10.349 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E10.351 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema E10.352 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula E10.353 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula E10.354 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment E10.355 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 7

Diabetes ( includes gestational) (con.'t) E10.359 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 E10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathy E10.618 Type 1 diabetes mellitus with other diabetic arthropathy E10.620 Type 1 diabetes mellitus with diabetic dermatitis E10.621 Type 1 diabetes mellitus with foot ulcer E10.622 Type 1 diabetes mellitus with other skin ulcer E10.628 Type 1 diabetes mellitus with other skin complications E10.630 Type 1 diabetes mellitus with periodontal disease E10.638 Type 1 diabetes mellitus with other oral complications E10.641 Type 1 diabetes mellitus with hypoglycemia with coma E10.649 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 E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema E11.321 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E11.329 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E11.331 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E11.339 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E11.341 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E11.349 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E11.351 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 8

Diabetes ( includes gestational) (con.'t) E11.352 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula E11.353 Type 2 diabetes mellitus with prolifera ve diabe c re nopathy with trac on re nal detachment not involving the macula E11.354 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment E11.355 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy E11.359 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 E11.610 Type 2 diabetes mellitus with diabetic neuropathic arthropathy E11.618 Type 2 diabetes mellitus with other diabetic arthropathy E11.620 Type 2 diabetes mellitus with diabetic dermatitis E11.621 Type 2 diabetes mellitus with foot ulcer E11.622 Type 2 diabetes mellitus with other skin ulcer E11.628 Type 2 diabetes mellitus with other skin complications E11.630 Type 2 diabetes mellitus with periodontal disease E11.638 Type 2 diabetes mellitus with other oral complications E11.641 Type 2 diabetes mellitus with hypoglycemia with coma E11.649 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 E13.311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema E13.319 Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema E13.321 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E13.329 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E13.331 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 9

Diabetes ( includes gestational) (con.'t) E13.339 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E13.341 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E13.349 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E13.351 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema E13.352 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula E13.353 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula E13.354 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment E13.355 Other specified diabetes mellitus with stable proliferative diabetic retinopathy E13.359 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 E13.610 Other specified diabetes mellitus with diabetic neuropathic arthropathy E13.618 Other specified diabetes mellitus with other diabetic arthropathy E13.620 Other specified diabetes mellitus with diabetic dermatitis E13.621 Other specified diabetes mellitus with foot ulcer E13.622 Other specified diabetes mellitus with other skin ulcer E13.628 Other specified diabetes mellitus with other skin complications E13.630 Other specified diabetes mellitus with periodontal disease E13.638 Other specified diabetes mellitus with other oral complications E13.641 Other specified diabetes mellitus with hypoglycemia with coma E13.649 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 O24.011 Pre existing type 1 diabetes mellitus, in pregnancy, first trimester O24.012 Pre existing type 1 diabetes mellitus, in pregnancy, second trimester O24.013 Pre existing type 1 diabetes mellitus, in pregnancy, third trimester O24.019 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 O24.111 Pre existing type 2 diabetes mellitus, in pregnancy, first trimester V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 10

Diabetes ( includes gestational) (con.'t) O24.112 Pre existing type 2 diabetes mellitus, in pregnancy, second trimester O24.113 Pre existing type 2 diabetes mellitus, in pregnancy, third trimester O24.119 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 O24.311 Unspecified pre existing diabetes mellitus in pregnancy, first trimester O24.312 Unspecified pre existing diabetes mellitus in pregnancy, second trimester O24.313 Unspecified pre existing diabetes mellitus in pregnancy, third trimester O24.319 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 O24.410 Gestational diabetes mellitus in pregnancy, diet controlled O24.414 Gestational diabetes mellitus in pregnancy, insulin controlled O24.415 Gestational diabetes mellitus in pregnancy, controlled by oral hypoglycemic drugs O24.419 Gestational diabetes mellitus in pregnancy, unspecified control O24.420 Gestational diabetes mellitus in childbirth, diet controlled O24.424 Gestational diabetes mellitus in childbirth, insulin controlled O24.425 Gestational diabetes mellitus in childbirth, controlled by oral hypoglycemic drugs O24.429 Gestational diabetes mellitus in childbirth, unspecified control O24.430 Gestational diabetes mellitus in the peurperium, diet controlled O24.434 Gestational diabetes mellitus in the peurperium, insulin controlled O24.435 Gestational diabetes mellitus in the puerperium, controlled by oral hypoglycemic drugs O24.439 Gestational diabetes mellitus in the puerperium, unspecified control O24.811 Other pre existing diabetes mellitus in pregnancy, first trimester O24.812 Other pre existing diabetes mellitus in pregnancy, second trimester O24.813 Other pre existing diabetes mellitus in pregnancy, third trimester O24.819 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 O24.911 Unspecified diabetes mellitus in pregnancy, first trimester O24.912 Unspecified diabetes mellitus in pregnancy, second trimester O24.913 Unspecified diabetes mellitus in pregnancy, third trimester O24.919 Unspecified diabetes mellitus in pregnancy, unspecified trimester O24.92 Unspecified diabetes mellitus in childbirth O24.93 Unspecified diabetes mellitus in the puerperium O99.810 Abnormal glucose complicating pregnancy O99.814 Abnormal glucose complicating childbirth O99.815 Abnormal glucose complicating the puerperium V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 11

Asthma O99.511 Diseases of the respiratory system complicating pregnancy, first trimester O99.512 Diseases of the respiratory system complicating pregnancy, second trimester O99.513 Diseases of the respiratory system complicating pregnancy, third trimester O99.519 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 J45.901 Unspecified asthma with (acute) exacerbation J45.902 Unspecified asthma with status asthmaticus J45.909 Unspecified asthma, uncomplicated J45.990 Exercise induced bronchospasm J45.991 Cough variant asthma J45.998 Other asthma Tobacco Use O99.330 Smoking (tobacco) complicating pregnancy, unspecified trimester O99.331 Smoking (tobacco) complicating pregnancy, first trimester O99.332 Smoking (tobacco) complicating pregnancy, second trimester O99.333 Smoking (tobacco) complicating pregnancy, third trimester O99.334 Smoking (tobacco) complicating childbirth O99.335 Smoking (tobacco) complicating the puerperium Thyroid Disease O90.5 Postpartum thyroiditis O99.280 Endocrine, nutritional and metabolic diseases complicating pregnancy, unspecified trimester O99.281 Endocrine, nutritional and metabolic diseases complicating pregnancy, first trimester O99.282 Endocrine, nutritional and metabolic diseases complicating pregnancy, second trimester O99.283 Endocrine, nutritional and metabolic diseases complicating pregnancy, third trimester O99.284 Endocrine, nutritional and metabolic diseases complicating childbirth O99.285 Endocrine, nutritional and metabolic diseases complicating the puerperium Psychiatric Disease O99.340 Other mental disorders complicating pregnancy, unsp trimester O99.341 Other mental disorders complicating pregnancy, first trimester V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 12

Psychiatric Disease (con.'t) O99.342 Other mental disorders comp pregnancy, second trimester O99.343 Other mental disorders complicating pregnancy, third trimester O99.344 Other mental disorders complicating childbirth O99.345 Other mental disorders complicating the puerperium F53 Mental and behavioral disorders associated with the puerperium, not elsewhere classified Seizure Disorder O99.350 Diseases of the nervous system complicating pregnancy, unspecified trimester O99.351 Diseases of the nervous system complicating pregnancy, first trimester O99.352 Diseases of the nervous system complicating pregnancy, second trimester O99.353 Diseases of the nervous system complicating pregnancy, third trimester O99.354 Diseases of the nervous system complicating childbirth O99.355 Diseases of the nervous system complicating the puerperium V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 13

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 O34.211 Maternal care for low transverse scar from previous cesarean delivery O34.212 Maternal care for vertical scar from previous cesarean delivery O34.219 Maternal care for unspecified type scar from previous cesarean delivery Preterm Delivery/Labor O42.011 Preterm premature rupture of membranes, onset of labor within 24 hours of rupture, first trimester O42.012 Preterm premature rupture of membranes, onset of labor within 24 hours of rupture, second trimester O42.013 Preterm premature rupture of membranes, onset of labor within 24 hours of rupture, third trimester O42.019 Preterm premature rupture of membranes, onset of labor within 24 hours of rupture, unspecified trimester O42.111 Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, first trimester O42.112 Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, second trimester O42.113 Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, third trimester O42.119 Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, unspecified trimeste O42.911 first trimester O42.912 second trimester O42.913 third trimester O42.919 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

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] O45.001 Premature separation of placenta with coagulation defect, unspecified, first trimester O45.002 Premature separation of placenta with coagulation defect, unspecified, second trimester O45.003 Premature separation of placenta with coagulation defect, unspecified, third trimester O45.009 Premature separation of placenta with coagulation defect, unspecified, unspecified trimester O45.011 Premature separation of placenta with afibrinogenemia, first trimester O45.012 Premature separation of placenta with afibrinogenemia, second trimester O45.013 Premature separation of placenta with afibrinogenemia, third trimester O45.019 Premature separation of placenta with afibrinogenemia, unspecified trimester O45.021 Premature separation of placenta with disseminated intravascular coagulation, first trimester O45.022 Premature separation of placenta with disseminated intravascular coagulation, second trimester O45.023 Premature separation of placenta with disseminated intravascular coagulation, third trimester O45.029 Premature separation of placenta with disseminated intravascular coagulation, unspecified trimester O45.091 Premature separation of placenta with other coagulation defect, first trimester O45.092 Premature separation of placenta with other coagulation defect, second trimester O45.093 Premature separation of placenta with other coagulation defect, third trimester O45.099 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

Pregnancy Characteristics Abnormal Placentation (con.'t) O45.93 Premature separation of placenta, unspecified, third trimester O43.211 Placenta accreta, first trimester O43.212 Placenta accreta, second trimester O43.213 Placenta accreta, third trimester O43.219 Placenta accreta, unspecified trimester O43.221 Placenta increta, first trimester O43.222 Placenta increta, second trimester O43.223 Placenta increta, third trimester O43.229 Placenta increta, unspecified trimester O43.231 Placenta percreta, first trimester O43.232 Placenta percreta, second trimester O43.233 Placenta percreta, third trimester O43.239 Placenta percreta, unspecified trimester O69.4 Labor and delivery complicated by vasa previa V18.2 SPECIAL REPORT 2019 NPIC NPIC.ORG 16

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