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ICD-10 Guide
ICD-10 CodesO23.21

O23.21

Billable

Infections of urethra in pregnancy, first trimester

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

Code Description

ICD-10 O23.21 is a billable code used to indicate a diagnosis of infections of urethra in pregnancy, first trimester.

Key Diagnostic Point:

Infections of the urethra during the first trimester of pregnancy can pose significant risks to both the mother and the developing fetus. These infections, often categorized under urinary tract infections (UTIs), can lead to complications such as pyelonephritis, preterm labor, and low birth weight if left untreated. Symptoms may include dysuria, increased urinary frequency, and suprapubic pain. Diagnosis typically involves urinalysis and urine culture to identify the causative organism. Treatment is crucial and often involves the use of antibiotics that are safe for use during pregnancy. Common pathogens include Escherichia coli and other gram-negative bacteria. It is essential for healthcare providers to monitor the patient closely and adjust treatment as necessary, considering the potential impact on fetal development. Proper coding of this condition is vital for ensuring appropriate care and reimbursement.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between types of urinary tract infections.
  • Understanding antibiotic safety profiles in pregnancy.
  • Documenting symptoms and laboratory findings accurately.
  • Recognizing potential complications associated with untreated infections.

Audit Risk Factors

  • Inadequate documentation of symptoms leading to misdiagnosis.
  • Failure to document antibiotic treatment and its appropriateness.
  • Lack of follow-up notes regarding the patient's response to treatment.
  • Incorrect coding of the trimester or severity of the infection.

Specialty Focus

Medical Specialties

Obstetrics and Gynecology

Documentation Requirements

Detailed documentation of patient history, presenting symptoms, and treatment plans is essential. Providers should also note any relevant laboratory results.

Common Clinical Scenarios

A pregnant patient presents with dysuria and increased urinary frequency during her first trimester, leading to a diagnosis of urethral infection.

Billing Considerations

Consideration of the safety of prescribed antibiotics and monitoring for potential side effects is crucial.

Maternal-Fetal Medicine

Documentation Requirements

Documentation must include risk factors for complications, maternal health status, and fetal monitoring results.

Common Clinical Scenarios

A high-risk pregnant patient with a history of recurrent UTIs presents with new onset urinary symptoms.

Billing Considerations

Close monitoring of both maternal and fetal health is necessary, especially in cases of severe infection.

Coding Guidelines

Inclusion Criteria

Use O23.21 When
  • According to ICD
  • 10 coding guidelines, it is essential to specify the trimester of pregnancy when coding for infections
  • Accurate documentation of the patient's condition and treatment is necessary to support the diagnosis

Exclusion Criteria

Do NOT use O23.21 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

87086CPT Code

Urine culture, bacterial

Clinical Scenario

Used when a pregnant patient presents with urinary symptoms and requires confirmation of infection.

Documentation Requirements

Document the reason for the culture and any relevant clinical findings.

Specialty Considerations

Ensure that the culture is performed in a timely manner to guide appropriate antibiotic therapy.

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, improving the accuracy of diagnoses and treatment plans. O23.21 provides a clear indication of the condition and its timing in pregnancy.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of obstetric conditions, improving the accuracy of diagnoses and treatment plans. O23.21 provides a clear indication of the condition and its timing in pregnancy.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of obstetric conditions, improving the accuracy of diagnoses and treatment plans. O23.21 provides a clear indication of the condition and its timing in pregnancy.

Resources

Clinical References

  • •
    CDC Guidelines for Urinary Tract Infections in Pregnancy

Coding & Billing References

  • •
    CDC Guidelines for Urinary Tract Infections in Pregnancy

Frequently Asked Questions

What are the common symptoms of urethral infections in pregnancy?

Common symptoms include dysuria, increased frequency of urination, urgency, and suprapubic pain. It is important for pregnant patients to report these symptoms promptly to their healthcare provider.