ICD-10-CM Codes O00-O9A
Official Guidelines for Coding and Reporting,
Section I.C.15
© Kathleen Peterson, MS, RHIA, CCS
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ICD-10-CM
Code
ICD-10-CM Code Description
Z30.01-
Encounter for initial prescription of contraceptives
Z30.02
Counseling & instruction in natural family planning to avoid
pregnancy
Z30.09
Encounter for other general counseling & advice on contraception
Z30.4
Encounter for surveillance of contraceptives
Z31.-
Encounter for procreative management
Z32.-
Encounter for pregnancy test & childbirth & childcare instruction
Z33.1
Pregnant state, incidental
• Used in place of chapter 15 codes; provider must state the
condition treated is not affecting pregnancy
Z34.-
Encounter for supervision of normal pregnancy
Z3A.-
Weeks of gestation
Z39.-
Encounter for maternal postpartum care & examination
© Kathleen Peterson, MS, RHIA, CCS
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Provider sees a pregnant women
at 25 weeks gestation for
persistent pain in right ear which
has worsened over the last 5
days. The provider determines
the patient has acute serous
otitis media in right ear; this
condition is not related to
pregnancy. Antibiotics are
prescribed.
A 22-year-old primigravida
female patient presents for first
OB visit. She is approximately 7
weeks pregnant. After
examination, patient is
prescribed prenatal vitamins and
will return in 4 weeks for followup.
Pregnancy Incidental
Normal Pregnancy
© Kathleen Peterson, MS, RHIA, CCS
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ICD-10-CM coding guideline, Section I.C.15.q

Abortion with live fetus
◦ Z33.2 Encounter for elective termination of pregnancy with code from
category Z37, Outcome of Delivery
◦ By definition, a live fetus is a fetus having any heartbeat, respiration or
involuntary muscle movement after expulsion, no matter how long it
survives.

Retained products of conception following an abortion
◦ Use appropriate code from category O03, Spontaneous abortion, or codes
O07.4, Failed attempted termination of pregnancy without complication
and Z33.2, Encounter for elective termination of pregnancy.

Complications leading to abortion
◦ Any code from chapter 15 for documented complications of pregnancy
may be assigned with codes in categories O07 and O08.
© Kathleen Peterson, MS, RHIA, CCS
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

The expulsion or extraction from the uterus of all
or part of the products of conception
 An embryo or a nonviable fetus weighing less
than 500 grams
Spontaneous – one that occurs without any
instrumentation or chemical intervention
 Treatment: D&C, aspiration D&C, or suction D&C
may be performed immediately following abortion
if there is a question of incomplete abortion
 Performing D&C is not evidence of incomplete
abortion
© Kathleen Peterson, MS, RHIA, CCS
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
Definition: unexpected AB occurs when patient undergoes
major trauma or surgery during pregnancy resulting in loss of
fetus
◦ Direct inadvertent AB - patient loses fetus, after surgery on
uterus for condition unrelated to pregnancy
 PDX = condition occasioning admission
 SDX = Z33.2 (to indicate termination of pregnancy
occurred)
◦ Indirect inadvertent AB - patient loses fetus, after major
trauma or surgery other than on uterus
 PDX = condition occasioning admission
 SDX = O03.9 (classify as spontaneous AB)
© Kathleen Peterson, MS, RHIA, CCS
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


Missed AB: occurs when the fetus had died before
completion of 20 weeks gestation, with retention in the
uterus for 4 or more weeks.
◦ Use code O02.1
Missed Intrauterine death: occurs when the fetus had died
after completion of 20 weeks gestation, with retention of the
dead fetus.
◦ Use code O36.4Missed abortion with blighted ovum, nonhydatidiform mole or
hydatidiform mole is assigned to O02.0 or a code from
category O01, Hydatidiform mole
© Kathleen Peterson, MS, RHIA, CCS
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


O00 Ectopic pregnancy
◦ Abdominal, tubal, ovarian, other
O01 Hydatidiform mole
◦ Particular type of molar pregnancy
◦ Molar pregnancy occurs when a blighted ovum
within the uterus develops into a mole or benign
tumor.
O02 Other abnormal product of conception
© Kathleen Peterson, MS, RHIA, CCS
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Assign ICD-10-CM codes for:
1. Incomplete, spontaneous abortion at 9 weeks gestation
2. Ectopic pregnancy, right fallopian tube
© Kathleen Peterson, MS, RHIA, CCS
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Section I.C.15.a
 OB cases require codes from Chapter 15
 Chapter 15 codes have sequencing priorities over codes from
other chapters
 Additional codes from other chapters may also be assigned to
specify conditions.
 Provider must document if the condition being treated does
not affect the pregnancy.
 Chapter 15 codes only used on mother’s record.
 Final characters indicate the trimester for most chapter 15
codes
◦ Assign based upon provider documentation of the trimester
for the admission or encounter
◦ Use “in childbirth” option for codes when delivery occurs
during current admission
© Kathleen Peterson, MS, RHIA, CCS
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ICD-10-CM Coding Guidelines, Section I.C.15.b.
 Circumstances of encounter determine selection of PDX or first-listed
diagnosis
◦ Selection of PDX  main circumstances or complication of delivery
 If C-section, PDX is condition after study responsible for patient’s
admission
 When C-section is performed, the condition responsible for patient’s
admission may or may not be the same as the reason for the Csection



Routine outpatient prenatal visits → Z34.- may not use with any OB
complication code.
Routine outpatient prenatal visits for high-risk pregnancies → category
O09 as first listed diagnosis; followed by chapter 15 codes.
OB episodes without delivery → code principal complication of pregnancy
resulting in encounter.
© Kathleen Peterson, MS, RHIA, CCS
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
Look under the following main terms
◦
◦
◦
◦
◦

Pregnancy
Delivery
Puerperal, Puerperium
Specific complication
Outcome of delivery (Category Z37, only on delivery
record only)
In the encoder, search the main term,
complicated by, disorder
e.g.,
Pregnancy
e.g., mental
disorder
© Kathleen Peterson, MS, RHIA, CCS
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



Only assign to maternal record
Indicates weeks of gestation of the pregnancy
Look at the prenatal record to find
information
Z3A.01 – Z3A.42
◦ Less than 8 weeks – greater than 42 weeks
◦ Z3A.00 Weeks of gestation, not specified - Rarely
used
© Kathleen Peterson, MS, RHIA, CCS
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


Antepartum = Prenatal Period: from time of
conception to beginning of regular uterine
contractions
Labor and Delivery
Postpartum = Puerperium: begins with end of
the 3rd stage of labor and continues for 6
weeks
© Kathleen Peterson, MS, RHIA, CCS
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
Preterm
◦ delivery before 37 completed weeks of gestation

Term
◦ delivery between 38 and 42 weeks of gestation

Post-term
◦ delivery after 42 weeks of gestation
© Kathleen Peterson, MS, RHIA, CCS
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



See instructional note at beginning of chapter
15
1st trimester: less than 14 weeks 0 days
2nd trimester: 14 weeks 0 days to less than 28
weeks 0 days
3rd trimester: 28 weeks 0 days until delivery
© Kathleen Peterson, MS, RHIA, CCS
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Official Guidelines for Coding & Reporting, Section I.C.15.n
What does it mean?
 Minimal or no assistance
 With or without episiotomy
 Without fetal manipulation (fetal presentation is occipital or cephalic)
 Antepartum conditions resolved prior to admission for delivery
 Single, full-term infant
 Vaginal delivery
◦ Episiotomy without forceps
◦ Episiorrhaphy
◦ Amniotomy (AROM)
◦ Manually assisted delivery without forceps
◦ Administration of analgesia &/or anesthesia
◦ Fetal monitoring
◦ Sterilization
◦ Spontaneous, cephalic, vaginal full-term, single liveborn infant
◦ Don’t use with any other codes from chapter 15
◦ Use additional outcome of delivery code Z37.0
© Kathleen Peterson, MS, RHIA, CCS
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
Chapter 15 codes may distinguish between preexisting conditions and those due to pregnancy
◦ Pre-existing hypertension – see category O10
◦ Gestational [pregnancy-induced] hypertension –
see categories O13, O14, O15
◦ Pre-existing diabetes mellitus – see category
O24, with specific codes from E08-E13
◦ Gestational [pregnancy-induced] diabetes –
O24.4-
© Kathleen Peterson, MS, RHIA, CCS
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
O30 Twin, Triplet, Quadruplet, and other
specified multiple gestation
◦ Number of placentas
◦ Number of amniotic sacs

O31 Complications specific to multiple
gestations
◦ When assigning codes from O31, you must also
assign a code from O30
© Kathleen Peterson, MS, RHIA, CCS
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
Beginning with category O31, some category / subcategory
codes have instructional note about assigning 7th character
◦ 0 assigned for single gestation and multiple gestations
where fetus is unspecified
◦ 1 -5 assigned for fetuses 1 through 5
◦ 9 assigned for other fetus

Example: Single pregnancy, 13 weeks gestation, with
maternal care for Rh incompatibility
◦ O36.0910 (Maternal care for other Rh antibodies, single gestation)
◦ Z3A.13 Weeks of gestation – 13 weeks
© Kathleen Peterson, MS, RHIA, CCS
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Assign ICD-10-CM codes for:
Case 1
Intrauterine pregnancy, 12 weeks gestation,
undelivered with mild hyperemesis gravidarium
Case 2: Intrauterine pregnancy at 40 weeks
gestation, delivered;
Assisted spontaneous vaginal delivery, left
occipitoanterior [presentation]; Single liveborn infant.
© Kathleen Peterson, MS, RHIA, CCS
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Encounter for an HIV-related illness
 O98.71- Human immunodeficiency virus
[HIV] disease complicating pregnancy
◦ Also report B20 for symptomatic HIV disease /AIDS
Encounter for asymptomatic HIV infection
status
 O98.71- Human immunodeficiency virus
[HIV] disease complicating pregnancy
◦ Also report Z21for asymptomatic HIV infection
status
© Kathleen Peterson, MS, RHIA, CCS
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
Report a code from O24.- Diabetes mellitus
in pregnancy, childbirth, and puerperium
◦ Also assign code from categories E08-E13 for type
of diabetes and any specific complications and/or
manifestations

For diabetes which is treated with insulin,
assign Z79.4, Long-term (current) use of
insulin
© Kathleen Peterson, MS, RHIA, CCS
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


Occurs during 2nd and 3rd trimesters in patients without
pre-pregnancy diagnosis of diabetes mellitus
Assign code from O24.4- Gestational diabetes mellitus
◦ Provider must document how the gestational diabetes
is controlled
 By diet or by insulin
 By both diet and insulin – use Z79.4 as additional
code
For abnormal glucose tolerance test during pregnancy,
assign O99.810
© Kathleen Peterson, MS, RHIA, CCS
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


Alcohol use during pregnancy
◦ O99.31- [use 6th character to identify trimester]
◦ Use additional code from F10.- Alcohol related disorders
to identify manifestations of alcohol use
Tobacco use during pregnancy
◦ O99.33- [use 6th character to identify trimester]
◦ Use additional code from F17.- documented nicotine
dependence or Z72.0 documented tobacco use
Drug use during pregnancy
◦ O99.32- [use 6th character to identify trimester]
◦ Use additional code from F11-F16 & F18-F19 to identify
manifestations of drug use
© Kathleen Peterson, MS, RHIA, CCS
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


Maternal infectious and parasitic diseases
◦ O98.- [use 6th character to identify trimester]
◦ Use additional code (chapter 1), to identify specific infectious or
parasitic diseases
Other maternal diseases complicating pregnancy
◦ Anemia, diseases of specific body systems)
◦ O99.- [use 6th character to identify trimester]
◦ Follow instructional notes to use additional codes for specific
disease
 O99.82- Strep B carrier status [use 6th character to identify
trimester]
Maternal malignant neoplasms, traumatic injuries & abuse
◦ O9A.- [use 6th character to identify trimester]
◦ Use additional code (from specific chapter) to identify the
condition
© Kathleen Peterson, MS, RHIA, CCS
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Assign ICD-10-CM codes for:
Case 1
Rubella in female patient at 14 weeks gestation,
single fetus, undelivered
Case 2: Prenatal visit for a 30-year-old female who
developed gestational diabetes at 26 weeks
gestation; treated by diet.
Case 3: Female patient at 10 weeks gestation with
acute pyelonephritis
© Kathleen Peterson, MS, RHIA, CCS
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