(Induced) termination of pregnancy with unspecified complications
ICD-10 O04.80 is a billable code used to indicate a diagnosis of (induced) termination of pregnancy with unspecified complications.
O04.80 refers to the induced termination of pregnancy where complications are not specified. This code encompasses various methods of termination, including medical abortion (using medications such as mifepristone and misoprostol) and surgical procedures (such as suction curettage or dilation and evacuation). The decision to terminate a pregnancy may arise from various factors, including maternal health concerns, fetal anomalies, or psychosocial reasons. The absence of specified complications indicates that the procedure was completed without immediate adverse effects, although potential complications such as infection, hemorrhage, or psychological impact may still be present. Proper documentation is crucial to capture the circumstances surrounding the termination, including gestational age, method used, and any pre-existing conditions that may influence the procedure. This code is essential for accurately reflecting the care provided and ensuring appropriate reimbursement for services rendered.
Documentation must include the reason for termination, method used, gestational age, and any relevant medical history.
Elective termination for personal reasons, therapeutic termination due to maternal health issues, and post-abortion follow-up care.
Consideration of local laws regarding termination and the need for informed consent documentation.
Detailed documentation of maternal-fetal risks, indications for termination, and any complications encountered.
High-risk pregnancies where termination is necessary due to severe fetal anomalies or maternal health risks.
Focus on the medical necessity of the procedure and comprehensive risk assessment.
Used when a medical abortion is performed, typically in an outpatient setting.
Documentation of medication administered, patient consent, and follow-up care.
Obstetricians must ensure compliance with state regulations regarding medical abortion.
Used for surgical termination of pregnancy, often in a hospital setting.
Detailed operative report and post-operative care notes.
Ensure documentation reflects the necessity of the procedure.
Documentation must include the reason for termination, method used, gestational age, and any relevant medical history. Follow-up care notes are also important to support the coding.
