Q&A: Boosting consistency when reporting postpartum hemorrhage
Q: What are the most common reasons postpartum hemorrhage is documented and coded inconsistently, and how can coders and clinicians help address these issues?
A: As one of the top five causes of maternal mortality worldwide, postpartum hemorrhage (PPH) is a global challenge that impacts maternity units everywhere and must be taken seriously by healthcare systems. Preventing PPH requires timely recognition, availability of appropriate resources, and appropriate responses. According to hemorrhage-associated maternal mortality ratios published by the American Journal of Obstetrics and Gynecology, there is a higher ratio of PPH for non-Hispanic Black and Hispanic patients compared to non-Hispanic white patients, highlighting why equity and standardization are critical in addressing PPH.
Many drivers for coding PPH tend to be related to processes and documentation rather than clinical causes. Specific non-clinical causes include documentation of estimated blood loss, template errors, lack of standardized definitions, and absence of coding and CDI reviews. Inconsistent documentation can make it hard to identify true hemorrhage cases, and electronic templates may not always be aligned with current clinical practices, leading to codes that do not represent the true clinical picture of patients. There should be a specific place to document estimated blood loss with consistent measurement guidelines available across all template types.
Additionally, different teams should not be using different criteria for what qualifies as a PPH. Without an extra layer of review from audits, important details can miss these differences, impacting both data integrity and care insights. Standardized criteria should also be available to distinguish PPH from what is considered normal postoperative or normal postpartum bleeding. A lack of clarity will impact coding, reporting, and even accurate benchmarking, particularly when one provider's hemorrhage is another person's normal. Before outcomes can be improved, measurements have to be agreed upon.
As for the coding side, coding pathways may default to PPH whenever uterine atony with a mention of bleeding is documented, even if the clinical picture does not meet the criteria. If there is no formal audit process for PPH coding accuracy, these cases could end up completely excluded from reviews, creating a blind spot in review processes. Improving outcomes goes beyond clinical interventions and into fixing the systems that support care delivery.
To resolve these non-clinical issues, coding and CDI teams should start with standardizing definitions, redesigning templates, improving documentation workflows, and expanding reviews into targeted cases. Because accurate documentation of estimated blood loss is the cornerstone of identifying PPH early, teams should work with nursing and together implement focused initiatives that are all about measurement consistency. For example, set a standard for using weight based on milliliter measurements. Then focus on programming electronic record systems to automatically convert measurements to milliliters so that no mental calculations are required to maintain consistency.
Adopting the definition of PPH by the American College of Obstetrics and Gynecologists can also keep teams on the same page. With everyone playing by the same rules, clinical templates should be revised to include mandatory sections for estimated blood loss through documentation prompts so that providers can’t skip this critical step. Finally, adding peer-to-peer education on coding and CDI queries will further encourage consistency across teams.
Now focusing in on the coding and CDI world further, determine if coding trees are actually leading coders straight to PPH whenever uterine atony or bleeding are mentioned, because even the best documentation can't guarantee accurate data if coding pathways are flawed. According to Coding Clinic, routine or expected hemorrhage during delivery is not supposed to be reported unless the provider documents that the bleeding is excessive or is a complication.
If the documentation is unclear, coders should query the provider, not just report a code from ICD-10-CM category O72, Postpartum hemorrhage. Building query templates for both coding and CDI teams further ensures consistency, which can help close the gap between the clinical reality at the bedside and the coded data.
Editor’s note: This question and answer were excerpted from the HCPro webinar, “Every Birth, Every Mother: Partnering to Reduce Postpartum Hemorrhage with Excellence,” presented by Laura Ogaard, RN, MSN, CCDS, director of education for Intermountain Physician Services, and Sathya Vijayakumar, MS, MBA, LSSGB, director with Intermountain Physician Advisor Services, Clinical Excellence. It originally appeared in JustCoding.