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ICD-10 Guide
ICD-10 CodesO34.02

O34.02

Billable

Maternal care for unspecified congenital malformation of uterus, second trimester

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

Code Description

ICD-10 O34.02 is a billable code used to indicate a diagnosis of maternal care for unspecified congenital malformation of uterus, second trimester.

Key Diagnostic Point:

O34.02 refers to maternal care for unspecified congenital malformations of the uterus during the second trimester of pregnancy. Congenital malformations of the uterus can include a variety of structural abnormalities such as uterine agenesis, unicornuate uterus, or septate uterus, which may impact pregnancy outcomes. These conditions can lead to complications such as miscarriage, preterm labor, or abnormal fetal positioning. During the second trimester, maternal care focuses on monitoring the health of both the mother and fetus, assessing any potential complications arising from the uterine malformation, and planning for delivery. Care may involve imaging studies like ultrasound to evaluate the uterine structure and fetal development, as well as consultations with specialists in maternal-fetal medicine if the malformation poses significant risks. Additionally, previous cesarean deliveries and uterine scarring may complicate the management of pregnancies with uterine malformations, necessitating careful planning for delivery to minimize risks to both mother and child.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in congenital malformation types and their implications for pregnancy.
  • Need for detailed documentation of maternal and fetal assessments.
  • Potential for multiple specialists to be involved in care.
  • Increased risk of complications requiring careful monitoring.

Audit Risk Factors

  • Inadequate documentation of the type and impact of the uterine malformation.
  • Failure to document consultations with specialists.
  • Lack of clear linkage between diagnosis and treatment provided.
  • Inconsistent coding of related conditions or complications.

Specialty Focus

Medical Specialties

Obstetrics and Gynecology

Documentation Requirements

Documentation must include detailed descriptions of the uterine malformation, any associated symptoms, and the management plan.

Common Clinical Scenarios

Management of pregnancies complicated by uterine malformations, including monitoring for preterm labor or fetal distress.

Billing Considerations

Consideration of previous cesarean deliveries and uterine scarring is crucial for planning delivery.

Maternal-Fetal Medicine

Documentation Requirements

High-risk pregnancy documentation must include comprehensive assessments of maternal and fetal health, imaging results, and multidisciplinary care plans.

Common Clinical Scenarios

Complex cases involving uterine malformations that require specialized monitoring and intervention.

Billing Considerations

High-risk factors necessitate close collaboration with obstetricians and other specialists.

Coding Guidelines

Inclusion Criteria

Use O34.02 When
  • According to ICD
  • 10 coding guidelines, accurate coding for maternal care requires specificity regarding the type of malformation and its implications for pregnancy
  • Documentation must reflect the trimester of care and any complications that arise

Exclusion Criteria

Do NOT use O34.02 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

76801CPT Code

Ultrasound, pelvic, transabdominal

Clinical Scenario

Used to assess uterine structure and fetal development in cases of congenital malformation.

Documentation Requirements

Documentation must include indications for the ultrasound and findings related to the uterine malformation.

Specialty Considerations

Obstetricians should ensure that the ultrasound findings are clearly linked to the diagnosis.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for greater specificity in coding congenital malformations of the uterus, enabling better tracking of outcomes and complications associated with these conditions.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for greater specificity in coding congenital malformations of the uterus, enabling better tracking of outcomes and complications associated with these conditions.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for greater specificity in coding congenital malformations of the uterus, enabling better tracking of outcomes and complications associated with these conditions.

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 are the implications of a congenital malformation of the uterus during pregnancy?

Congenital malformations of the uterus can lead to various complications during pregnancy, including increased risk of miscarriage, preterm labor, and abnormal fetal positioning. Careful monitoring and management are essential to optimize outcomes for both mother and baby.