8 Major Documentation Changes for OB/GYN in ICD-10

Obstetrics and Gynecology codes have undergone major revisions in ICD-10-CM/PCS. We now have 2,155 obstetrical codes in ICD-10, which are twice as many codes as compared to ICD-9. Out of the lot, over 1/3 of the expansion of codes is due to addition of laterality. The Chapter 15 of the ICD-10-CM Manual requires coders to report specific trimester of the patient’s pregnancy. If you think it’s easier to specify the anatomical location and laterality in your documentation—then think again!

Let’s take a look at some major changes.

  1. In ICD-10-CM, the trimesters are established from the first day of the last menstrual period.

1st trimester: Fewer than 14 weeks 0 days

2nd trimester: 14 weeks 0 days to fewer than 28 weeks 0 days

3rd trimester: 28 weeks 0 days until delivery

ICD-10 code examples
    O09.01 Supervision of pregnancy with history of infertility, first trimester
    O60.02 Preterm labor without delivery, second trimester


  1. In ICD 10, the code for an annual GYN exam is located in Chapter 21, instead of Chapter 15. For instance, Code Z01.4- signifies an encounter for a routine GYN exam
  ICD-10 Examples
   Encounter for general GYN exam with or without cervical smear
    Encounter for GYN exam (general) (routine), not otherwise specified
    Encounter for pelvic exam (annual) (periodic)


  1. In ICD-10-CM, there are four spontaneous abortion definitions:

Missed abortion No bleeding, os closed

Threatened abortion Bleeding, os closed

Incomplete abortion Bleeding, os open, products of conception are extruding

Complete abortion Possible bleeding or spotting, os closed, all products of conception expelled

ICD-10 Example
O02.1 Missed abortion
O36.4XX1 Maternal care for intrauterine death, fetus 1
Z33.2 Encounter for elective termination of pregnancy


  1. ICD-10-CM will also see elimination of episodes of care for obstetric codes. Additionally, there are changes in timeframes:
    Abortion vs. Fetal death (20 weeks)
    Early vs. Late pregnancy (20 weeks)


  1. In ICD-10-CM, the coders will now be able to report the specific gestational week of pregnancy with codes from category Z3A. Gestational week codes would be reported along with codes for complications of pregnancy.
ICD 10 Examples of the Gestational Week Code Structure
Z3A.0 Weeks of gestation of pregnancy, unspecified or less than 10 weeks
Z3A.00 Weeks of gestation of pregnancy not specified
Z3A.01 Less than 8 weeks gestation of pregnancy
Z3A.08 8 weeks gestation of pregnancy
Z3A.09 9 weeks gestation of pregnancy


  1. The complication in pregnancy has been taken care of in ICD-10-CM. For instance, Diabetes Mellitus in pregnancy has been divided into 6 subcategories, which are further sub-classified for valid reporting.
    Pre-existing DM, type 1
    Pre-existing DM, type 2
    Unspecified pre-existing DM
    Gestational DM
    Other pre-existing DM
    Unspecified DM

 These subcategories have codes specifying the trimester of pregnancy, in childbirth, and in the puerperium.

7.     In ICD 10, while documenting intent of encounter, you need to include the type of encounter and complications.

Z30.011 Encounter for initial prescription of contraceptive pills
Z31.82 Encounter for Rh incompatibility status
Z39.1 Encounter for care and examination of lactating mothers


  1. In ICD 10, we now have a normal delivery code O80. This should be assigned when a woman is admitted for a full- term normal delivery and delivers a healthy single infant without any complications (antepartum, during the delivery, or postpartum). Coders can add additional codes with code O80 if they are not in any way complicating the pregnancy. Code O80 may also be used if the patient had a complication at some point during the pregnancy, although the complication is not present at the time of the admission for delivery.


O74 Complications of anesthesia during labor and delivery
O65.5 Obstructed labor due to abnormality of maternal pelvic organs
O70 Perineal laceration during delivery Includes: episiotomy extended by laceration

The above discussion reveals remarkable changes in obstetrics and gynecology coding. ICD-10-CM/PCS is clearly providing more current terminology for these clinical services. The take-home message from this blog is that the documentation of trimester is significant. For more learning, check out this information packed audio session at AudioEducator, http://www.audioeducator.com/ob-gyn/icd-10-cm-obstertic-guidelines-04-07-2015.html

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