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ICD-10 Guide
ICD-10 CodesO26.31

O26.31

Billable

Retained intrauterine contraceptive device in pregnancy, first trimester

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

Code Description

ICD-10 O26.31 is a billable code used to indicate a diagnosis of retained intrauterine contraceptive device in pregnancy, first trimester.

Key Diagnostic Point:

The diagnosis O26.31 refers to the presence of a retained intrauterine contraceptive device (IUD) during the first trimester of pregnancy. This condition can complicate pregnancy due to the potential for adverse effects on both maternal and fetal health. The presence of an IUD can lead to complications such as ectopic pregnancy, miscarriage, or preterm labor. It is crucial for healthcare providers to monitor the patient closely, as the retained device may necessitate removal or special management to ensure the safety of both the mother and the developing fetus. The management plan may involve ultrasound assessments to determine the position of the IUD and to evaluate any associated complications. Additionally, counseling regarding the risks and benefits of removal versus retention of the device is essential for informed decision-making. The first trimester is a critical period for fetal development, making careful monitoring and management of this condition vital.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between retained IUD and other pregnancy complications.
  • Understanding the implications of IUD presence on maternal and fetal health.
  • Navigating the documentation requirements for high-risk pregnancies.
  • Coordinating care among multiple specialties, including obstetrics and maternal-fetal medicine.

Audit Risk Factors

  • Inadequate documentation of the patient's history with the IUD.
  • Failure to document the clinical decision-making process regarding IUD management.
  • Misclassification of the pregnancy trimester.
  • Lack of follow-up documentation regarding the outcome of the pregnancy.

Specialty Focus

Medical Specialties

Obstetrics and Gynecology

Documentation Requirements

Detailed documentation of the patient's obstetric history, current pregnancy status, and management plan for the retained IUD.

Common Clinical Scenarios

Patients presenting with retained IUDs, experiencing complications such as bleeding or cramping.

Billing Considerations

Consideration of the patient's preferences and informed consent regarding management options.

Maternal-Fetal Medicine

Documentation Requirements

Comprehensive documentation of maternal and fetal assessments, including ultrasound findings and risk assessments.

Common Clinical Scenarios

High-risk pregnancies with retained IUDs requiring specialized monitoring and intervention.

Billing Considerations

Focus on the potential impact of the retained IUD on fetal development and maternal health.

Coding Guidelines

Inclusion Criteria

Use O26.31 When
  • According to official coding guidelines, O26
  • 31 should be used when a retained IUD is confirmed during the first trimester of pregnancy
  • Coders must ensure accurate documentation of the patient's condition and any associated complications to support the use of this code

Exclusion Criteria

Do NOT use O26.31 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

58300CPT Code

Insertion of intrauterine device

Clinical Scenario

Used when a patient presents for IUD insertion prior to pregnancy confirmation.

Documentation Requirements

Document the patient's consent and the procedure details.

Specialty Considerations

Obstetricians should ensure proper coding for IUD management.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of obstetric conditions, including retained IUDs, which enhances the accuracy of patient records and billing.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of obstetric conditions, including retained IUDs, which enhances the accuracy of patient records and billing.

Reimbursement & Billing Impact

billing.

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 I document if a patient has a retained IUD during pregnancy?

Document the patient's obstetric history, the presence of the IUD, any symptoms or complications, and the management plan. Ensure that all clinical findings are clearly recorded to support the diagnosis.