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ICD-10 Guide
ICD-10 CodesO28.3

O28.3

Billable

Abnormal ultrasonic finding on antenatal screening of mother

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/08/2025

Code Description

ICD-10 O28.3 is a billable code used to indicate a diagnosis of abnormal ultrasonic finding on antenatal screening of mother.

Key Diagnostic Point:

Abnormal ultrasonic findings during antenatal screening can indicate a variety of maternal and fetal conditions that may require further evaluation and management. These findings can include anomalies in fetal anatomy, abnormal placentation, or signs of potential complications such as gestational hypertension or intrauterine growth restriction. The identification of these abnormalities is crucial as they can significantly impact the management of the pregnancy and the health of both the mother and the fetus. Clinicians must carefully document the nature of the abnormal findings, the follow-up actions taken, and any additional testing or referrals made. This ensures that appropriate care is provided and that the coding accurately reflects the complexity of the case. The abnormal findings may lead to increased surveillance, consultations with specialists, or interventions that can affect the course of the pregnancy.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in ultrasound findings and their interpretations
  • Need for additional diagnostic testing and follow-up
  • Documentation of maternal and fetal implications
  • Potential for multiple co-existing conditions

Audit Risk Factors

  • Inadequate documentation of ultrasound findings
  • Failure to document follow-up actions taken
  • Misinterpretation of ultrasound results
  • Inconsistent coding of related conditions

Specialty Focus

Medical Specialties

Obstetrics and Gynecology

Documentation Requirements

Detailed documentation of ultrasound findings, maternal health status, and any interventions or referrals made.

Common Clinical Scenarios

Routine antenatal screenings revealing abnormal findings, such as suspected fetal anomalies or placental issues.

Billing Considerations

Ensure that all findings are clearly documented, including the gestational age at which the ultrasound was performed and any subsequent management plans.

Maternal-Fetal Medicine

Documentation Requirements

Comprehensive documentation of high-risk factors, detailed ultrasound reports, and any multidisciplinary consultations.

Common Clinical Scenarios

High-risk pregnancies with abnormal findings necessitating specialized care, such as suspected congenital anomalies or placental insufficiency.

Billing Considerations

Focus on the implications of findings for maternal and fetal health, and ensure that all relevant data is captured for coding.

Coding Guidelines

Inclusion Criteria

Use O28.3 When
  • Follow official ICD
  • CM coding guidelines, ensuring that the code is used only when there is documented evidence of abnormal findings on ultrasound
  • Coders should also be aware of the need for specificity in documenting the nature of the findings and any related conditions

Exclusion Criteria

Do NOT use O28.3 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

76801CPT Code

Ultrasound, pregnant uterus, transabdominal, real-time with image documentation, fetal and maternal evaluation

Clinical Scenario

Used during routine antenatal visits to assess fetal development and detect abnormalities.

Documentation Requirements

Document the findings, gestational age, and any follow-up recommendations.

Specialty Considerations

Obstetricians should ensure that all relevant clinical information is included in the report.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for greater specificity in coding abnormal ultrasound findings, enabling better tracking of maternal and fetal outcomes and improving the quality of care.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for greater specificity in coding abnormal ultrasound findings, enabling better tracking of maternal and fetal outcomes and improving the quality of care.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for greater specificity in coding abnormal ultrasound findings, enabling better tracking of maternal and fetal outcomes and improving the quality of care.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What should be documented when using code O28.3?

Documentation should include the specific abnormal findings from the ultrasound, the gestational age at which the ultrasound was performed, any follow-up actions taken, and the implications for the management of the pregnancy.