ICD-10-CM Coding for Malposition/Malpresentation of Fetus

Fetal positioning within the uterus is not of much concern until the third trimester which is when most fetuses assume a head down position in preparation for descent into the birth canal. Optimal fetal positioning makes labor and delivery faster, easier and safer for both the fetus and the mother. Fetal malposition or malpresentation may lead to difficulties with labor and delivery and can be an indication for as assisted vaginal birth or delivery by cesarean section. Proper code assignment for malposition and malpresentation is necessary to support performance of these procedures for these conditions.

What is Fetal Presentation, Position and Lie?

Fetal presentation, position and lie describe the fetus in relation to the uterus, cervix and maternal pelvis.

• Fetal presentation refers to the part of the fetus that is lined up to enter the maternal pelvis first/lead the fetus through the cervix (e.g., occiput, chin, shoulder, foot).
• Fetal position refers to the position of the fetal head as it exits the birth canal. This indicates the direction the fetus is facing (anterior, posterior, transverse).
• Fetal lie refers to how the long axis of the fetus (think spinal column) lines up in relation to the uterus. The lie can be longitudinal (straight up and down), oblique (diagonal) or transverse (sideways). 

Normal or optimal presentation, position and lie for vaginal obstetric delivery is:

• Presentation: Vertex/cephalic (the crown of the head) with chin tucked to chest and arms crossed over the chest
• Position: Occiput anterior (the baby is facing toward the mother’s spine)
• Lie: Longitudinal (straight up and down).

What is Malpresentation/Malposition?

Malpresentations and malpositions result when one or a combination of the fetal presentation, position or lie deviates from the normal/optimal status. Below are examples of malpresentations, malpositions, and abnormal lie.

Malpresentation

• Breech: The buttocks and/or feet are the presenting part of the fetus
  • Frank breech: Buttocks down with feet near the head
  • Complete breech: Knees bent with feet near the buttocks
  • Incomplete breech: One knee bent with one foot near the buttocks
  • Footling breech: One or both feet are the presenting part
• Face/Brow/Chin (mentum): The fetus’ neck is hyperextended (arched) making the face, brow or chin the presenting fetal part. The degree of hyperextension determines which part is presenting. Greater extension presents the face/chin, less extension presents the brow.
• Shoulder/arm: The shoulder or arm is the presenting part of the fetus
• High head at term: The fetal head does not engage in the pelvis
• Compound: A fetal extremity presents alongside the part of the fetus closest to the birth canal (e.g., hand/arm presents alongside the head)

Malposition

• Occipitoposterior: The fetus’ occiput (back of the head) is against the posterior (spinal) side of the mother and the fetus is facing toward the mother’s abdomen. This is sometimes referred to as “sunny side up”.
• Occipitotransverse: This position is halfway between an anterior and a posterior position. The side of the fetus is perpendicular to the mother’s spine and the fetus is facing outward toward the mother’s right or left thigh. 

Abnormal Lie

• Oblique: The fetus is lying diagonally.
• Transverse: The fetus is lying sideways.
• Unstable: The fetus does not maintain a fixed longitudinal lie after 36 weeks gestation.
  
  

How is Malpresentation/Malposition Coded in ICD-10-CM?

Codes for malpresentation and/or malposition of fetus are found in category O32 Maternal care for malpresentation of fetus. Notice that the description of each code specifies that the code is used to report maternal care for a specific type of malpresentation/malposition.

032.0 Maternal care for unstable lie

032.1 Maternal care for breech presentation

• Maternal care for buttocks presentation
• Maternal care for complete breech
• Maternal care for frank breech
  
  
• Excludes 1: footling presentation (032.8); incomplete breech (032.8)

032.2 Maternal care for transverse and oblique lie

• Maternal care for oblique presentation
• Maternal care for transverse presentation

032.3 Maternal care for face, brow and chin presentation

032.4 Maternal care for high head at term

• Maternal care for failure of head to enter pelvic brim

032.6 Maternal care for compound presentation

032.8 Maternal care for other malpresentation of fetus

• Maternal care for footling presentation
• Maternal care for incomplete breech

032.9 Maternal care for malpresentation of fetus, unspecified

Assignment of codes is determined by a applying a combination of direction found in the Alphabetic Index, the Tabular List and the ICD-10-CM official guidelines to the documentation in the medical record.

The Alphabetic Index

Selection of the correct code to report malpresentation/malposition is directed by a valid search of the Index to Diseases and Injuries. There are several ways the index can be searched to arrive at codes for malpresentation/malposition depending on the terminology used in the documentation.

Successful searches include:

Delivery
 cesarean (for)
    breech presentation O32.1
   chin presentation O32.3
   high head at term O32.4
    Etc.

Delivery
   complicated
      by
         malposition, malpresentation
            without obstruction
               breech O32.1
                compound O32.6
                face (brow) (chin) O32.3
                footling O32.8
      high head O32.4
     oblique O32.2
     specified NEC O32.8
     transverse O32.2
     unstable lie O32.0

Delivery
   complicated
      by
         prolapse
            arm or hand O32.2
             foot or leg O32.8

Failure
 descent of head (at term) of pregnancy (mother) O32.4
  engagement of head (term of pregnancy) (mother) O32.4

Pregnancy
   Complicated by
      mentum presentation O32.3
       oblique lie or presentation O32.2
       transverse lie or presentation O32.2
       unstable lie O32.0
       Etc.

Pregnancy
   Complicated by
      presentation, fetal -see Delivery, complicated by, malposition

Breech presentation (mother) O32.1

Transverse
   lie (mother) O32.2 

Unstable
   lie (mother) O32.0

Presentation, fetal -see Delivery , complicated by, malposition

The Tabular List

There are notes at the beginning of category O32 that provide important direction that must be followed when assigning codes from this category. For example:

• Codes from this category are assigned when malpresentation/malposition is the reason for maternal care
• When malpresentation causes obstructed labor, a code from category O64 is assigned rather than from category O32
• A 7^th character that reports the affected fetus is assigned to codes for malpresentation/malposition

O32 Maternal care for malpresentation of fetus

Includes: the listed conditions as a reason for observation, hospitalization or other obstetric care of the mother, or for cesarean delivery before onset of labor

Excludes1: malpresentation of fetus with obstructed labor (064.-)

One of the following 7th characters is to be assigned to each code under category 032. 7th character 0 is for single gestations and multiple gestations where the fetus is unspecified. 7th characters 1 through 9 are for cases of multiple gestations to identify the fetus for which the code applies. The appropriate code from category 030, Multiple gestation, must also be assigned when assigning a code from category O32 that has a 7th character of 1 through 9.

• 0 - not applicable or unspecified
• 1 - fetus 1
• 2 - fetus 2
• 3 - fetus 3
• 4 - fetus 4
• 5 - fetus 5
• 9 - other fetus

Note: Codes from category O32 only have 4 characters, so a placeholder character of “X” is needed in the 5^thand 6^th character places to ensure the character value assigned to indicate the affected fetus is in the 7^thcharacter place.

The ICD-10-CM Coding Guidelines

According to ICD-10-CM Official Guideline I.C.15.b.4 Selection of OB Principal or First-listed Diagnosis When a Delivery Occurs, malpresentation/malposition is sequenced as the principal diagnosis when:

• Malpresentation/malposition is the reason for admission.
• Malpresentation/malposition and another condition prompt the admission but malpresentation/malposition is most related to the delivery (e.g., it leads to instrumental vaginal delivery or is the reason for admission for cesarean section)
• The patient is admitted with no other complications of pregnancy and develops malpresentation/malposition post admission and malpresentation/malposition necessitates maternal care including, but not limited to: repositioning of the patient, rotation of fetal head, internal/external version, instrumental vaginal delivery (forceps/vacuum extraction).

In a small number of cases, how the fetus is situated may be a malpresentation/malposition but the malpresentation/malposition does not require maternal care. If this is the case, a code from category O32 is not assigned.

Example: A patient is admitted in advanced premature labor. The fetus is in vertex presentation, but in occiput posterior position (sunny side up). Due to the small size of the fetus, it is delivered via a normal, spontaneous vaginal delivery in the occiput posterior position.

Since the malposition of the fetus did not necessitate maternal care a code from category O32 is not assigned. This is consistent with the coding guidelines for selection of additional or other diagnoses.

Section III. Reporting Additional Diagnoses

GENERAL RULES FOR OTHER (ADDITIONAL) DIAGNOSES

For reporting purposes, the definition for “other diagnoses” is interpreted as additional clinically significant conditions that affect patient care in terms of requiring:

clinical evaluation; or

therapeutic treatment; or

diagnostic procedures; or

extended length of hospital stay; or

increased nursing care and/or monitoring

Malpresentation/Malposition as an Indication for Cesarean Section

In cases where vaginal delivery is contraindicated because of malpresentation, malposition or abnormal lie, a cesarean section may need to be performed to deliver the fetus safely.

The Includes note under category O32 in the Tabular List indicates codes from this category are intended to be reported when the decision to deliver a patient via cesarean section, secondary to malpresentation or malposition of the fetus, is made before the onset of labor.

O32 Maternal care for malpresentation of fetus

• Includes: the listed conditions as a reason for observation, hospitalization or other obstetric care of the mother, or for cesarean delivery before onset of labor

This distinction is important because when a patient presents in labor with the intent to delivery vaginally and malpresentation/malposition results in the decision to deliver the patient via cesarean this is typically because the malpresentation/malposition of the fetus has resulted in obstructed labor that precludes vaginal delivery. These circumstances are reported with a code from category O64 Obstructed labor due to malposition and malpresentation of fetus rather than with a code from category O32.

Take Aways

Malpresentations and malpositions result when one or a combination of the fetal presentation, position or lie deviates from the normal/optimal status. ICD-10-CM codes to report malpresentation/malposition are assigned from category O32 Maternal care for malpresentation of fetus when the malpresentation/malposition is the reason for maternal care. Code selection is guided by documentation in the medical record and a valid search of the Index to Diseases and Injuries. The ICD-10-CM Tabular List and coding guidelines provide significant direction regarding the requirements and structure for assigning a valid code and sequencing of codes from category O32 as the principal diagnosis.

References
ICD-10-CM Index to Diseases and Injuries
ICD-10-CM Official Guidelines for Coding and Reporting
ICD-10-CM Tabular List

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