Check out your future fall-back code for cases without indications noted.
As much as it might go against your coding instincts, sometimes you have no choice but to report a less-specific diagnosis code because the provider doesn't thoroughly document the situation. That can often be the case with labor and delivery charts, especially when the mother delivers by cesarean section.
Under current ICD-9 guidelines, you submit 669.71 (Cesarean delivery, without mention of indication, delivered with or without mention of antepartum condition) when you don't have details regarding the reason for c-section.
ICD-10 change:When ICD-10 goes into effect in October 2013, you'll still have a single code for cesarean delivery without an indication of the reason. Diagnosis O82 (Encounter for cesarean delivery without indication) will become your new option, along with related code O80 (Encounter for full-term uncomplicated delivery). You'll find both codes in Chapter 15 (Pregnancy, Childbirth and the Puerperium), subsection block [...]