V18.2 SPECIAL REPORT ©2019 NPIC NPIC.ORG | 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 al2, 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, non-

teaching), 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.

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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%. InFlorida, low readmission hospitals had a rate of 1.14% and high readmission hospitals had a rate of 2.00%. In New York, low readmissionhospitals 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 pregnancy-related hypertension and diabetes.

• There were higher rates of peripartum complication in the high readmission hospitals, with the highest rates being hemorrhage andhigher-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

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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 subgroupcompared 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 pregnancycharacteristics 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.

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V18.2 Special Report: Postpartum Readmissions

Hospital 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

Subgroup Averages

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

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APPENDIX AMaternal Comorbidities

ObesityO99.210 Obesity complicating pregnancy, unspecified trimesterO99.211 Obesity complicating pregnancy, first trimesterO99.212 Obesity complicating pregnancy, second trimesterO99.213 Obesity complicating pregnancy, third trimesterO99.214 Obesity complicating childbirthO99.215 Obesity complicating the puerperiumZ68.30  Body mass index (BMI) 30.0‐30.9, adultZ68.31  Body mass index (BMI) 31.0‐31.9, adultZ68.32  Body mass index (BMI) 32.0‐32.9, adultZ68.33  Body mass index (BMI) 33.0‐33.9, adultZ68.34  Body mass index (BMI) 34.0‐34.9, adultZ68.35  Body mass index (BMI) 35.0‐35.9, adultZ68.36 Body mass index (BMI) 36.0‐36.9, adultZ68.37  Body mass index (BMI) 37.0‐37.9, adultZ68.38  Body mass index (BMI) 38.0‐38.9, adultZ68.39  Body mass index (BMI) 39.0‐39.9, adultZ68.41  Body mass index (BMI) 40.0‐44.9, adultZ68.42  Body mass index (BMI) 45.0‐49.9, adultZ68.43  Body mass index (BMI) 50‐59.9 , adultZ68.44  Body mass index (BMI) 60.0‐69.9, adultZ68.45  Body mass index (BMI) 70 or greater, adult

Hypertensive Disorder O10 Pre‐existing hypertension complicating pregnancy, childbirth, and the puerperiumO10.011 Pre‐existing essential hypertension complicating pregnancy, first trimesterO10.012 Pre‐existing essential hypertension complicating pregnancy, second trimesterO10.013 Pre‐existing essential hypertension complicating pregnancy, third trimesterO10.019 Pre‐existing essential hypertension complicating pregnancy, unspecified trimesterO10.02 Pre‐existing essential hypertension complicating childbirthO10.03 Pre‐existing essential hypertension complicating the puerperiumO10.111 Pre‐existing hypertensive heart disease complicating pregnancy, first trimesterO10.112 Pre‐existing hypertensive heart disease complicating pregnancy, second trimesterO10.113 Pre‐existing hypertensive heart disease complicating pregnancy, third trimesterO10.119 Pre‐existing hypertensive heart disease complicating pregnancy, unspecified trimesterO10.12 Pre‐existing hypertensive heart disease complicating childbirthO10.13 Pre‐existing hypertensive heart disease complicating the puerperiumO10.211 Pre‐existing hypertensive chronic kidney disease complicating pregnancy, first trimesterO10.212 Pre‐existing hypertensive chronic kidney disease complicating pregnacy, second trimesterO10.213 Pre‐existing hypertensive chronic kidney disease complicating pregnancy, third trimesterO10.219 Pre‐existing hypertensive chronic kidney disease complicating pregnancy, unspecified trimesterO10.22 Pre‐existing hypertensive chronic kidney disease complicating childbirthO10.23 Pre‐existing hypertensive chronic kidney disease complicating the puerperiumO10.311 Pre‐existing hypertensive heart and chronic kidney disease complicating pregnancy, first trimesterO10.312 Pre‐existing hypertensive heart and chronic kidney disease complicating pregnancy, second trimester

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APPENDIX AMaternal ComorbiditiesHypertensive Disorder (con.'t)O10.313 Pre‐existing hypertensive heart and chronic kidney disease complicating pregnancy, third trimesterO10.319 Pre‐existing hypertensive heart and chronic kidney disease complicating pregnancy, unspecified trimesterO10.32 Pre‐existing hypertensive heart and chronic kidney disease complicating childbirthO10.33 Pre‐existing hypertensive heart and chronic kidney disease complicating the puerperiumO10.411 Pre‐existing secondary hypertension complicating pregnancy, first trimesterO10.412 Pre‐existing secondary hypertension complicating pregnancy, second trimesterO10.413 Pre‐existing secondary hypertension complicating pregnancy, third trimesterO10.419 Pre‐existing secondary hypertension complicating pregnancy, unspecified trimesterO10.42 Pre‐existing secondary hypertension complicating childbirthO10.43 Pre‐existing secondary hypertension complicating the puerperiumO10.911 Unspecified pre‐existing hypertension complicating pregnancy, first trimesterO10.912 Unspecified pre‐existing hypertension complicating pregnancy, second trimesterO10.913 Unspecified pre‐existing hypertension complicating pregnancy, third trimesterO10.919 Unspecified pre‐existing hypertension complicating pregnancy, unspecified trimesterO10.92 Unspecified pre‐existing hypertension complicating childbirthO10.93 Unspecified pre‐existing hypertension complicating the puerperiumO11 Pre‐existing hypertension with pre‐eclampsiaO11.1 Pre‐existing hypertension with pre‐eclampsia, first trimesterO11.2 Pre‐existing hypertension with pre‐eclampsia, second trimesterO11.3 Pre‐existing hypertension with pre‐eclampsia, third trimesterO11.4 Pre‐existing hypertension with pre‐eclampsia, complicating childbirthO11.5 Pre‐existing hypertension with pre‐eclampsia, complicating the puerperiumO11.9 Pre‐existing hypertension with pre‐eclampsia, unspecified trimester

Pregnancy Related Hypertensive Disorder O13 Gestational [pregnancy‐induced] hypertension without significant proteinuriaO13.1 Gestational hypertension w/o significant proteinuria, first trimesterO13.2 Gestational hypertension w/o significant proteinuria, second trimesterO13.3 Gestational hypertension w/o significant proteinuria, third trimesterO13.4  Gestational [pregnancy‐induced] hypertension without significant proteinuria, complicating child birth. O13.5  Gestational (pregnancy‐induced) hypertension without significant proteinuria, complicating the puerperiumO13.9  Gestational [pregnancy‐induced] hypertension without significant proteinuria, unspecified trimesterO14 Pre‐eclampsiaO14.00 Mild to moderate pre‐eclampsia, unspecifed trimesterO14.02 Mild to moderate pre‐eclampsia, second trimesterO14.03 Mild to moderate pre‐eclampsia, third trimesterO14.04 Mild to moderate pre‐eclampsia, complicating childbirthO14.05 Mild to moderate pre‐eclampsia, complicating the puerperiumO14.10 Severe pre‐eclampsia, unspecified trimesterO14.12 Severe pre‐eclampsia, second trimesterO14.13 Severe pre‐eclampsia, third trimesterO14.14 Severe pre‐eclampsia complicating childbirthO14.15 Severe pre‐eclampsia, complicating the puerperiumO14.20 HELLP syndrome (HELLP), unspecified trimester

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APPENDIX AMaternal ComorbiditiesPregnancy Related Hypertensive Disorder (con.'t)O14.22 HELLP syndrome (HELLP), second trimesterO14.23 HELLP syndrome (HELLP), third trimesterO14.24 HELLP syndrome, complicating childbirthO14.25 HELLP syndrome, complicating the puerperiumO14.90 Unspecified pre‐eclampsia, unspecified trimesterO14.92 Unspecified pre‐eclampsia, second trimesterO14.93 Unspecified pre‐eclampsia, third trimesterO14.94 Unspecified pre‐eclampsia, complicating childbirthO14.95 Unspecified pre‐eclampsia, complicating the puerperiumO15 EclampsiaO15.00 Eclampsia in pregnancy, unspecified trimesterO15.02 Eclampsia in pregnancy, second trimesterO15.03 Eclampsia in pregnancy, third trimesterO15.1 Eclampsia in laborO15.2 Eclampsia in the puerperiumO15.9 Eclampsia, unspecified as to time periodO16 Unspecified maternal hypertensionO16.1 Unspecified maternal hypertension, first trimesterO16.2 Unspecified maternal hypertension, second trimesterO16.3 Unspecified maternal hypertension, third trimesterO16.4  Unspecified maternal hypertension, complicating childbirthO16.5  Unspecified maternal hypertension, complicating the puerperiumO16.9 Unspecified maternal hypertension, unspecified trimester

Diabetes ( includes gestational)E10 Type 1 diabetes mellitus E10.10 Type 1 diabetes mellitus with ketoacidosis without comaE10.11 Type 1 diabetes mellitus with ketoacidosis with comaE10.21 Type 1 diabetes mellitus with diabetic nephropathyE10.22 Type 1 diabetes mellitus with diabetic chronic kidney diseaseE10.29 Type 1 diabetes mellitus with other diabetic kidney complicationE10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edemaE10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edemaE10.321 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edemaE10.329 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edemaE10.331 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edemaE10.339 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edemaE10.341 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edemaE10.349 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edemaE10.351 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edemaE10.352 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the maculaE10.353 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the maculaE10.354 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachmentE10.355 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy

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APPENDIX AMaternal ComorbiditiesDiabetes ( includes gestational) (con.'t)E10.359 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edemaE10.36 Type 1 diabetes mellitus with diabetic cataractE10.37 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatmentE10.39 Type 1 diabetes w oth diabetic ophthalmic complicationE10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecifiedE10.41 Type 1 diabetes mellitus with diabetic mononeuropathyE10.42 Type 1 diabetes mellitus with diabetic polyneuropathyE10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathyE10.44 Type 1 diabetes mellitus with diabetic amyotrophyE10.49 Type 1 diabetes mellitus with other diabetic neurological complicationE10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangreneE10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangreneE10.59 Type 1 diabetes mellitus with other circulatory complicationsE10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathyE10.618 Type 1 diabetes mellitus with other diabetic arthropathyE10.620 Type 1 diabetes mellitus with diabetic dermatitisE10.621 Type 1 diabetes mellitus with foot ulcerE10.622 Type 1 diabetes mellitus with other skin ulcerE10.628 Type 1 diabetes mellitus with other skin complicationsE10.630 Type 1 diabetes mellitus with periodontal diseaseE10.638 Type 1 diabetes mellitus with other oral complicationsE10.641 Type 1 diabetes mellitus with hypoglycemia with comaE10.649 Type 1 diabetes mellitus with hypoglycemia without comaE10.65 Type 1 diabetes mellitus with hyperglycemiaE10.69 Type 1 diabetes mellitus with other specified complicationE10.8 Type 1 diabetes mellitus with unspecified complicationsE10.9 Type 1 diabetes mellitus without complicationsE11 Type 2 diabetes mellitusE11.00 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic‐hyperosmolar coma (NKHHC)E11.01 Type 2 diabetes mellitus with hyperosmolarity with comaE11.10 Type 2 diabetes mellitus with ketoacidosis without comaE11.11 Type 2 diabetes mellitus with ketoacidosis with comaE11.21 Type 2 diabetes mellitus with diabetic nephropathyE11.22 Type 2 diabetes mellitus with diabetic chronic kidney diseaseE11.29 Type 2 diabetes mellitus with other diabetic kidney complicationE11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edemaE11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edemaE11.321 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edemaE11.329 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edemaE11.331 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edemaE11.339 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edemaE11.341 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edemaE11.349 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edemaE11.351 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema

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Sample

APPENDIX AMaternal ComorbiditiesDiabetes ( includes gestational) (con.'t)E11.352 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the maculaE11.353 Type 2 diabetes mellitus with prolifera ve diabe c re nopathy with trac on re nal detachment not involving the maculaE11.354 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachmentE11.355   Type 2 diabetes mellitus with stable proliferative diabetic retinopathyE11.359 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edemaE11.36 Type 2 diabetes mellitus with diabetic cataractE11.37 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatmentE11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complicationE11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecifiedE11.41 Type 2 diabetes mellitus with diabetic mononeuropathyE11.42 Type 2 diabetes mellitus with diabetic polyneuropathyE11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathyE11.44 Type 2 diabetes mellitus with diabetic amyotrophyE11.49 Type 2 diabetes mellitus with other diabetic neurological complicationE11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangreneE11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangreneE11.59 Type 2 diabetes mellitus with other circulatory complicationsE11.610 Type 2 diabetes mellitus with diabetic neuropathic arthropathyE11.618 Type 2 diabetes mellitus with other diabetic arthropathyE11.620 Type 2 diabetes mellitus with diabetic dermatitisE11.621 Type 2 diabetes mellitus with foot ulcerE11.622 Type 2 diabetes mellitus with other skin ulcerE11.628 Type 2 diabetes mellitus with other skin complicationsE11.630 Type 2 diabetes mellitus with periodontal diseaseE11.638 Type 2 diabetes mellitus with other oral complicationsE11.641 Type 2 diabetes mellitus with hypoglycemia with comaE11.649 Type 2 diabetes mellitus with hypoglycemia without comaE11.65 Type 2 diabetes mellitus with hyperglycemiaE11.69 Type 2 diabetes mellitus with other specified complicationE11.8 Type 2 diabetes mellitus with unspecified complicationsE11.9 Type 2 diabetes mellitus without complicationsE13 Other specified diabetes mellitusE13.00 Other specified diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic‐hyperosmolar coma (NKHHC)E13.01 Other specified diabetes mellitus with hyperosmolarity with comaE13.10 Other specified diabetes mellitus with ketoacidosis without comaE13.11 Other specified diabetes mellitus with ketoacidosis with comaE13.21 Other specified diabetes mellitus with diabetic nephropathyE13.22 Other specified diabetes mellitus with diabetic chronic kidney diseaseE13.29 Other specified diabetes mellitus with other diabetic kidney complicationE13.311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edemaE13.319 Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edemaE13.321 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edemaE13.329 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edemaE13.331 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema

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Sample

APPENDIX AMaternal ComorbiditiesDiabetes ( includes gestational) (con.'t)E13.339 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edemaE13.341 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edemaE13.349 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edemaE13.351 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edemaE13.352 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the maculaE13.353 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the maculaE13.354 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachmentE13.355 Other specified diabetes mellitus with stable proliferative diabetic retinopathyE13.359 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edemaE13.36 Other specified diabetes mellitus with diabetic cataractE13.37 Other specified diabetes mellitus with diabetic macular edema, resolved following treatmentE13.39 Other specified diabetes mellitus with other diabetic ophthalmic complicationE13.40 Other specified diabetes mellitus with diabetic neuropathy, unspecifiedE13.41 Other specified diabetes mellitus with diabetic mononeuropathyE13.42 Other specified diabetes mellitus with diabetic polyneuropathyE13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathyE13.44 Other specified diabetes mellitus with diabetic amyotrophyE13.49 Other specified diabetes mellitus with other diabetic neurological complicationE13.51 Other specified diabetes mellitus with diabetic peripheral angiopathy without gangreneE13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangreneE13.59 Other specified diabetes mellitus with other circulatory complicationsE13.610 Other specified diabetes mellitus with diabetic neuropathic arthropathyE13.618 Other specified diabetes mellitus with other diabetic arthropathyE13.620 Other specified diabetes mellitus with diabetic dermatitisE13.621 Other specified diabetes mellitus with foot ulcerE13.622 Other specified diabetes mellitus with other skin ulcerE13.628 Other specified diabetes mellitus with other skin complicationsE13.630 Other specified diabetes mellitus with periodontal diseaseE13.638 Other specified diabetes mellitus with other oral complicationsE13.641 Other specified diabetes mellitus with hypoglycemia with comaE13.649 Other specified diabetes mellitus with hypoglycemia without comaE13.65 Other specified diabetes mellitus with hyperglycemiaE13.69 Other specified diabetes mellitus with other specified complicationE13.8 Other specified diabetes mellitus with unspecified complicationsE13.9 Other specified diabetes mellitus without complicationsO24 Diabetes mellitus in pregnancy, childbirth, and the puerperiumO24.01 Pre‐existing type 1 diabetes mellitus, in pregnancyO24.011 Pre‐existing type 1 diabetes mellitus, in pregnancy, first trimesterO24.012 Pre‐existing type 1 diabetes mellitus, in pregnancy, second trimesterO24.013 Pre‐existing type 1 diabetes mellitus, in pregnancy, third trimesterO24.019 Pre‐existing type 1 diabetes mellitus, in pregnancy, unspecified trimesterO24.02 Pre‐existing type 1 diabetes mellitus, in childbirthO24.03 Pre‐existing type 1 diabetes mellitus, in the puerperiumO24.111 Pre‐existing type 2 diabetes mellitus, in pregnancy, first trimester

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Sample

APPENDIX AMaternal ComorbiditiesDiabetes ( includes gestational) (con.'t)O24.112 Pre‐existing type 2 diabetes mellitus, in pregnancy, second trimesterO24.113 Pre‐existing type 2 diabetes mellitus, in pregnancy, third trimesterO24.119 Pre‐existing type 2 diabetes mellitus, in pregnancy, unspecified trimesterO24.12 Pre‐existing type 2 diabetes mellitus, in childbirthO24.13 Pre‐existing type 2 diabetes mellitus, in the puerperiumO24.31 Unspecified pre‐existing diabetes mellitus in pregnancyO24.311 Unspecified pre‐existing diabetes mellitus in pregnancy, first trimesterO24.312 Unspecified pre‐existing diabetes mellitus in pregnancy, second trimesterO24.313 Unspecified pre‐existing diabetes mellitus in pregnancy, third trimesterO24.319 Unspecified pre‐existing diabetes mellitus in pregnancy, unspecified trimesterO24.32 Unspecified pre‐existing diabetes mellitus in childbirthO24.33 Unspecified pre‐existing diabetes mellitus in the puerperiumO24.410 Gestational diabetes mellitus in pregnancy, diet controlledO24.414 Gestational diabetes mellitus in pregnancy, insulin controlledO24.415 Gestational diabetes mellitus in pregnancy, controlled by oral hypoglycemic drugsO24.419 Gestational diabetes mellitus in pregnancy, unspecified controlO24.420 Gestational diabetes mellitus in childbirth, diet controlledO24.424 Gestational diabetes mellitus in childbirth, insulin controlledO24.425 Gestational diabetes mellitus in childbirth, controlled by oral hypoglycemic drugsO24.429 Gestational diabetes mellitus in childbirth, unspecified controlO24.430 Gestational diabetes mellitus in the peurperium, diet controlledO24.434 Gestational diabetes mellitus in the peurperium, insulin controlledO24.435 Gestational diabetes mellitus in the puerperium, controlled by oral hypoglycemic drugsO24.439 Gestational diabetes mellitus in the puerperium, unspecified controlO24.811 Other pre‐existing diabetes mellitus in pregnancy, first trimesterO24.812 Other pre‐existing diabetes mellitus in pregnancy, second trimesterO24.813 Other pre‐existing diabetes mellitus in pregnancy, third trimesterO24.819 Other pre‐existing diabetes mellitus in pregnancy, unspecified trimesterO24.82 Other pre‐existing diabetes mellitus in childbirthO24.83 Other pre‐existing diabetes mellitus in the puerperiumO24.911 Unspecified diabetes mellitus in pregnancy, first trimesterO24.912 Unspecified diabetes mellitus in pregnancy, second trimesterO24.913 Unspecified diabetes mellitus in pregnancy, third trimesterO24.919 Unspecified diabetes mellitus in pregnancy, unspecified trimesterO24.92 Unspecified diabetes mellitus in childbirthO24.93 Unspecified diabetes mellitus in the puerperiumO99.810 Abnormal glucose complicating pregnancyO99.814 Abnormal glucose complicating childbirthO99.815 Abnormal glucose complicating the puerperium

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Sample

APPENDIX AMaternal ComorbiditiesAsthmaO99.511 Diseases of the respiratory system complicating pregnancy, first trimesterO99.512 Diseases of the respiratory system complicating pregnancy, second trimesterO99.513 Diseases of the respiratory system complicating pregnancy, third trimesterO99.519 Diseases of the respiratory system complicating pregnancy, unspecified trimesterO99.52 Diseases of the respiratory system complicating childbirthO99.53 Diseases of the respiratory system complicating the puerperiumJ45 AsthmaJ45.20 Mild intermittent asthma, uncomplicatedJ45.21 Mild intermittent asthma with (acute) exacerbationJ45.22 Mild intermittent asthma with status asthmaticusJ45.30 Mild persistent asthma, uncomplicatedJ45.31 Mild persistent asthma with (acute) exacerbationJ45.32 Mild persistent asthma with status asthmaticusJ45.40 Moderate persistent asthma, uncomplicatedJ45.41 Moderate persistent asthma with (acute) exacerbationJ45.42 Moderate persistent asthma with status asthmaticusJ45.50 Severe persistent asthma, uncomplicatedJ45.51 Severe persistent asthma with (acute) exacerbationJ45.52 Severe persistent asthma with status asthmaticusJ45.901 Unspecified asthma with (acute) exacerbationJ45.902 Unspecified asthma with status asthmaticusJ45.909 Unspecified asthma, uncomplicatedJ45.990 Exercise induced bronchospasmJ45.991 Cough variant asthmaJ45.998 Other asthma

Tobacco Use O99.330 Smoking (tobacco) complicating pregnancy, unspecified trimesterO99.331 Smoking (tobacco) complicating pregnancy, first trimesterO99.332 Smoking (tobacco) complicating pregnancy, second trimesterO99.333 Smoking (tobacco) complicating pregnancy, third trimesterO99.334 Smoking (tobacco) complicating childbirthO99.335 Smoking (tobacco) complicating the puerperium

Thyroid Disease O90.5 Postpartum thyroiditisO99.280 Endocrine, nutritional and metabolic diseases complicating pregnancy, unspecified trimesterO99.281 Endocrine, nutritional and metabolic diseases complicating pregnancy, first trimesterO99.282 Endocrine, nutritional and metabolic diseases complicating pregnancy, second trimesterO99.283 Endocrine, nutritional and metabolic diseases complicating pregnancy, third trimesterO99.284 Endocrine, nutritional and metabolic diseases complicating childbirthO99.285 Endocrine, nutritional and metabolic diseases complicating the puerperium

Psychiatric DiseaseO99.340 Other mental disorders complicating pregnancy, unsp trimesterO99.341 Other mental disorders complicating pregnancy, first trimester

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Sample

APPENDIX AMaternal ComorbiditiesPsychiatric Disease (con.'t)O99.342 Other mental disorders comp pregnancy, second trimesterO99.343 Other mental disorders complicating pregnancy, third trimesterO99.344 Other mental disorders complicating childbirthO99.345 Other mental disorders complicating the puerperiumF53 Mental and behavioral disorders associated with the puerperium, not elsewhere classified

Seizure DisorderO99.350  Diseases of the nervous system complicating pregnancy, unspecified trimesterO99.351  Diseases of the nervous system complicating pregnancy, first trimesterO99.352  Diseases of the nervous system complicating pregnancy, second trimesterO99.353  Diseases of the nervous system complicating pregnancy, third trimesterO99.354  Diseases of the nervous system complicating childbirthO99.355  Diseases of the nervous system complicating the puerperium

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Sample

APPENDIX APregnancy Characteristics

Multiple GestationZ37.2 Twins, both inbornZ37.3 Twins, one liveborn and one stillbornZ37.4 Twins, both stillbornZ37.50 Multiple births, unspecified, all livebornZ37.51 Triplets, all livebornZ37.52 Quadruplets, all livebornZ37.53 Quintuplets, all livebornZ37.54 Sextuplets, all livebornZ37.59 Other multiple births, all livebornZ37.60 Multiple births, unspecified, some livebornZ37.61 Triplets, some livebornZ37.62 Quadruplets, some livebornZ37.63 Quintuplets, some livebornZ37.64 Sextuplets, some livebornZ37.69 Other multiple births, some livebornZ37.7 Other multiple births, all stillborn

Prior Cesarean Delivery O34.211 Maternal care for low transverse scar from previous cesarean deliveryO34.212 Maternal care for vertical scar from previous cesarean deliveryO34.219 Maternal care for unspecified type scar from previous cesarean delivery

Preterm Delivery/LaborO42.011 Preterm premature rupture of membranes, onset of labor within 24 hours of rupture, first trimesterO42.012 Preterm premature rupture of membranes, onset of labor within 24 hours of rupture, second trimesterO42.013 Preterm premature rupture of membranes, onset of labor within 24 hours of rupture, third trimesterO42.019 Preterm premature rupture of membranes, onset of labor within 24 hours of rupture, unspecified trimesterO42.111 Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, first trimesterO42.112 Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, second trimesterO42.113 Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, third trimesterO42.119 Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, unspecified trimesteO42.911 first trimesterO42.912 second trimesterO42.913 third trimesterO42.919 unspecified trimesterO60.10 Preterm labor with preterm delivery, unspecified trimesterO60.12 Preterm labor second trimester with preterm delivery second trimesterO60.13 Preterm labor second trimester with preterm delivery third trimesterO60.14 Preterm labor third trimester with preterm delivery third trimester

Abnormal PlacentationO44 Placenta previaO44.00 Complete placenta previa NOS or without hemorrhage, unspecified trimesterO44.01 Complete placenta previa NOS or without hemorrhage, first trimesterO44.02 Complete placenta previa NOS or without hemorrhage, second trimesterO44.03 Complete placenta previa NOS or without hemorrhage, third trimester

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Sample

APPENDIX APregnancy CharacteristicsAbnormal Placentation (con.'t)O44.10 Complete placenta previa with hemorrhage, unspecified trimesterO44.11 Complete placenta previa with hemorrhage, first trimesterO44.12 Complete placenta previa with hemorrhage, second trimesterO44.13 Complete placenta previa with hemorrhage, third trimesterO44.20 Partial placenta previa NOS or without hemorrhage, unspecified trimesterO44.21 Partial placenta previa NOS or without hemorrhage, first trimesterO44.22 Partial placenta previa NOS or without hemorrhage, second trimesterO44.23 Partial placenta previa NOS or without hemorrhage, third trimesterO44.30 Partial placenta previa with hemorrhage, unspecified trimesterO44.31 Partial placenta previa with hemorrhage, first trimesterO44.32 Partial placenta previa with hemorrhage, second trimesterO44.33  Partial placenta previa with hemorrhage, third trimesterO44.40 Low lying placenta NOS or without hemorrhage, unspecified trimesterO44.41 Low lying placenta NOS or without hemorrhage, first trimesterO44.42 Low lying placenta NOS or without hemorrhage, second trimesterO44.43 Low lying placenta NOS or without hemorrhage, third trimesterO44.50 Low lying placenta with hemorrhage, unspecified trimesterO44.51 Low lying placenta with hemorrhage, first trimesterO44.52 Low lying placenta with hemorrhage, second trimesterO44.53 Low lying placenta with hemorrhage, third trimesterO45 Premature separation of placenta [abruption placentae]O45.001 Premature separation of placenta with coagulation defect, unspecified, first trimesterO45.002 Premature separation of placenta with coagulation defect, unspecified, second trimesterO45.003 Premature separation of placenta with coagulation defect, unspecified, third trimesterO45.009 Premature separation of placenta with coagulation defect, unspecified, unspecified trimesterO45.011 Premature separation of placenta with afibrinogenemia, first trimesterO45.012 Premature separation of placenta with afibrinogenemia, second trimesterO45.013 Premature separation of placenta with afibrinogenemia, third trimesterO45.019 Premature separation of placenta with afibrinogenemia, unspecified trimesterO45.021 Premature separation of placenta with disseminated intravascular coagulation, first trimesterO45.022 Premature separation of placenta with disseminated intravascular coagulation, second trimesterO45.023 Premature separation of placenta with disseminated intravascular coagulation, third trimesterO45.029 Premature separation of placenta with disseminated intravascular coagulation, unspecified trimesterO45.091 Premature separation of placenta with other coagulation defect, first trimesterO45.092 Premature separation of placenta with other coagulation defect, second trimesterO45.093 Premature separation of placenta with other coagulation defect, third trimesterO45.099 Premature separation of placenta with other coagulation defect, unspecified trimesterO45.8X1 Other premature separation of placenta, first trimesterO45.8X2 Other premature separation of placenta, second trimesterO45.8X3 Other premature separation of placenta, third trimesterO45.8X9 Other premature separation of placenta, unspecified trimesterO45.90 Premature separation of placenta, unspecified, unspecified trimesterO45.91 Premature separation of placenta, unspecified, first trimesterO45.92 Premature separation of placenta, unspecified, second trimester

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Sample

APPENDIX APregnancy CharacteristicsAbnormal Placentation (con.'t)O45.93 Premature separation of placenta, unspecified, third trimesterO43.211 Placenta accreta, first trimesterO43.212 Placenta accreta, second trimesterO43.213 Placenta accreta, third trimesterO43.219 Placenta accreta, unspecified trimesterO43.221 Placenta increta, first trimesterO43.222 Placenta increta, second trimesterO43.223 Placenta increta, third trimesterO43.229 Placenta increta, unspecified trimesterO43.231 Placenta percreta, first trimesterO43.232 Placenta percreta, second trimesterO43.233 Placenta percreta, third trimesterO43.239 Placenta percreta, unspecified trimesterO69.4 Labor and delivery complicated by vasa previa

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Sample

APPENDIX A

Payer Mix DefinitionsPublic: Medicare

MedicaidChampus/TricareHMO/MedicaidOther Government 

Private: Blue CrossCommercial InsuranceHMO

Other: Worker's CompOther

SelfFree Care

Unknown/Missing

Uninsured/Self pay:

Unknown/Missing:

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Sample