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ICD-10 Guide
ICD-10 CodesO34.61

O34.61

Billable

Maternal care for abnormality of vagina, first trimester

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

Code Description

ICD-10 O34.61 is a billable code used to indicate a diagnosis of maternal care for abnormality of vagina, first trimester.

Key Diagnostic Point:

O34.61 refers to maternal care for abnormalities of the vagina during the first trimester of pregnancy. This code is utilized when a pregnant woman presents with congenital or acquired abnormalities of the vagina that may affect her pregnancy. Such abnormalities can include vaginal agenesis, septate vagina, or other structural issues that may complicate the pregnancy or delivery. The first trimester is a critical period for fetal development, and any abnormalities in the maternal pelvic organs can lead to increased risks for both the mother and the fetus. Careful monitoring and management are essential, especially in cases where there is a history of previous cesarean deliveries or uterine scarring, which may further complicate the clinical picture. The healthcare provider must document the specific nature of the vaginal abnormality, any associated symptoms, and the management plan to ensure appropriate coding and care.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in types of vaginal abnormalities
  • Need for detailed documentation of the condition
  • Potential for associated complications with previous cesarean sections
  • Impact of uterine scarring on delivery options

Audit Risk Factors

  • Inadequate documentation of the vaginal abnormality
  • Failure to note previous obstetric history
  • Misclassification of the type of abnormality
  • Lack of clarity in the management plan

Specialty Focus

Medical Specialties

Obstetrics and Gynecology

Documentation Requirements

Documentation must include the specific type of vaginal abnormality, any symptoms, and the treatment plan.

Common Clinical Scenarios

A patient with vaginal agenesis presenting for prenatal care, or a patient with a history of vaginal surgery seeking care during pregnancy.

Billing Considerations

Consideration of how the abnormality may affect labor and delivery, including potential need for cesarean delivery.

Maternal-Fetal Medicine

Documentation Requirements

Detailed documentation of maternal-fetal risks associated with vaginal abnormalities, including imaging studies if performed.

Common Clinical Scenarios

Management of a high-risk pregnancy due to a significant vaginal anomaly or previous uterine surgery.

Billing Considerations

Focus on the implications of the abnormality for fetal development and delivery.

Coding Guidelines

Inclusion Criteria

Use O34.61 When
  • According to ICD
  • 10 coding guidelines, O34
  • 61 should be used when there is a confirmed diagnosis of a vaginal abnormality during the first trimester
  • Coders must ensure that the diagnosis is well
  • documented and that any associated conditions are also coded appropriately

Exclusion Criteria

Do NOT use O34.61 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

59400CPT Code

Obstetric care including antepartum care, delivery, and postpartum care

Clinical Scenario

Used for comprehensive obstetric care for patients with vaginal abnormalities.

Documentation Requirements

Complete documentation of all prenatal visits, delivery details, and postpartum follow-up.

Specialty Considerations

Obstetricians must document any complications arising from vaginal abnormalities.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of vaginal abnormalities, which aids in better tracking of maternal and fetal outcomes. This specificity helps in research and quality improvement initiatives in obstetric care.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of vaginal abnormalities, which aids in better tracking of maternal and fetal outcomes. This specificity helps in research and quality improvement initiatives in obstetric care.

Reimbursement & Billing Impact

reimbursement and to avoid claim denials.

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 for O34.61?

Documentation should include the specific type of vaginal abnormality, any associated symptoms, previous obstetric history, and the management plan for the pregnancy.