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ICD-10 Guide
ICD-10 CodesO04.88

O04.88

Billable

Urinary tract infection following (induced) termination of pregnancy

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

Code Description

ICD-10 O04.88 is a billable code used to indicate a diagnosis of urinary tract infection following (induced) termination of pregnancy.

Key Diagnostic Point:

Urinary tract infections (UTIs) can occur following an induced termination of pregnancy, whether medical or surgical. The risk factors for developing a UTI post-abortion include the use of catheters during the procedure, hormonal changes, and alterations in the vaginal flora. Symptoms may include dysuria, increased urinary frequency, and suprapubic pain. Clinicians should be vigilant in monitoring for UTIs in patients who have undergone a termination, as these infections can lead to further complications if left untreated. Management typically involves antibiotic therapy tailored to the specific pathogen identified through urinalysis and culture. It is essential for healthcare providers to educate patients on signs of infection and the importance of follow-up care to ensure complete recovery and prevent complications.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between types of termination (medical vs. surgical)
  • Identifying the timing of the UTI in relation to the termination procedure
  • Understanding the patient's medical history and risk factors
  • Documenting the specific treatment provided for the UTI

Audit Risk Factors

  • Inadequate documentation of the termination procedure
  • Failure to document the onset of UTI symptoms
  • Lack of follow-up care documentation
  • Misclassification of the type of termination

Specialty Focus

Medical Specialties

Obstetrics and Gynecology

Documentation Requirements

Detailed records of the termination procedure, including type, date, and any complications.

Common Clinical Scenarios

Patients presenting with UTI symptoms post-abortion, follow-up visits for infection management.

Billing Considerations

Ensure accurate coding based on the type of termination and any complications that arise.

Maternal-Fetal Medicine

Documentation Requirements

Comprehensive documentation of maternal health, fetal conditions, and any high-risk factors.

Common Clinical Scenarios

Management of high-risk pregnancies requiring termination and subsequent infection monitoring.

Billing Considerations

Consideration of maternal-fetal implications when coding for infections post-termination.

Coding Guidelines

Inclusion Criteria

Use O04.88 When
  • According to ICD
  • 10 coding guidelines, O04
  • 88 should be used when a urinary tract infection is specifically documented as occurring after an induced termination of pregnancy
  • Coders must ensure that the documentation clearly indicates the timing and nature of the termination

Exclusion Criteria

Do NOT use O04.88 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

58661CPT Code

Induced abortion, suction curettage

Clinical Scenario

Used when a surgical abortion is performed, and UTI develops post-procedure.

Documentation Requirements

Document the procedure details, including indications and any complications.

Specialty Considerations

Obstetricians should ensure accurate coding of both the procedure and any subsequent infections.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of complications following terminations, improving the accuracy of data collection and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of complications following terminations, improving the accuracy of data collection and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

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 documentation is required for coding O04.88?

Documentation must include the type of termination performed, the date of the procedure, the onset of UTI symptoms, and any treatments administered. Follow-up care details are also essential.