Calculation and Coding of Cesarean Birth Rates

While no single cesarean birth rate goal can be prescribed for a single clinician’s practice or care setting, our community has long known that a critical component of addressing maternal health and preventable maternal mortality and severe morbidity is safe reduction of primary cesarean birth.

Efforts to avoid primary cesareans have been multifactorial and have spanned our health care delivery system. For example, safe reduction of nulliparous, term, singleton, vertex (NTSV) cesarean birth has become a proxy measure for quality of care, as part of many payer models, and is a reported voluntary performance measure, measure PC-02, of The Joint Commission. Many widespread quality improvement endeavors through perinatal quality collaboratives and the Alliance for Innovation on Maternal Health in hospitals and health systems have shown promising results in reducing NTSV rates.

Unfortunately, some efforts have been misrepresented or misunderstood, leading to confusion among ACOG members, who are increasingly turning to ACOG’s Quality and Safety team for answers.

Specifically, The Joint Commission recently released the addition of exclusions of billing codes to instructions used in the calculation of NTSV cesarean birth rates. This code is related to “obstructed labor due to other malposition and malpresentation.” Specifically, this exclusion is meant to address footling breech and incomplete presentation or malposition not elsewhere coded when the NTSV birth rate is being calculated. This has led to some quality improvement professionals and obstetricians surmising that fetal position involving incomplete rotation of the fetal head is a condition that will now be excluded from NTSV calculation.

However, this updated exclusion coding was not intended to widely change practice or provide exclusion of instances of NTSV cesarean births. Instances where a fetus may be presenting in occipitoposterior, occipitotransverse, or other types of synclitic rotation in the birthing pelvis should continue to be included in NTSV calculation. In fact, the coding instructions for this performance measure states that ICD-10 code O64.0x, which is applicable in occipitoposterior, occipitosacral, occipitotransverse, deep transverse arrest, incomplete rotation of fetal head, and asynclitic presentations should specifically not be excluded from NTSV rate calculation.

“While appropriate and necessary cesarean birth may itself be a critical component of patient safety, it would be unfortunate and disruptive to the committed and ongoing work our members and colleagues are implementing to reduce NTSV cesarean births if facilities and systems were to dramatically change their methodology of coding for these births at this juncture due to misunderstanding of coding updates,” stated Christie Allen, ACOG’s senior director of quality improvement and programs. “Great care should be taken for consistency and accuracy in calculation of this measure with updated changes, and as always the intent of the NTSV cesarean birth rate calculation is to monitor and collaborate on provision of the highest quality and most equitable patient care we know that health care teams seek to provide.”

For more detailed information, see the California Maternal Quality Care Collaborative Maternal Data Center’s coding recommendations for obstructed labor due to malposition.