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ICD-10 Guide
ICD-10 CodesO23.521

O23.521

Billable

Salpingo-oophoritis in pregnancy, first trimester

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

Code Description

ICD-10 O23.521 is a billable code used to indicate a diagnosis of salpingo-oophoritis in pregnancy, first trimester.

Key Diagnostic Point:

Salpingo-oophoritis is an inflammatory condition affecting the fallopian tubes and ovaries, which can occur during pregnancy, particularly in the first trimester. This condition is often associated with infections of the genitourinary tract, including sexually transmitted infections (STIs) such as Chlamydia trachomatis and Neisseria gonorrhoeae, as well as other bacterial infections. Symptoms may include pelvic pain, fever, and abnormal vaginal discharge. Diagnosis typically involves a combination of clinical evaluation, imaging studies such as ultrasound, and laboratory tests to identify the causative organism. Treatment usually involves the use of antibiotics that are safe for use during pregnancy, as well as supportive care. It is crucial to manage this condition promptly to prevent complications such as ectopic pregnancy or preterm labor. Coders must ensure accurate documentation of the diagnosis, treatment, and any associated complications to facilitate appropriate coding and billing.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between salpingo-oophoritis and other pelvic inflammatory diseases.
  • Understanding the implications of pregnancy on treatment options.
  • Navigating antibiotic safety in pregnancy.
  • Documenting associated symptoms and complications accurately.

Audit Risk Factors

  • Inadequate documentation of symptoms leading to misdiagnosis.
  • Failure to document the specific trimester of pregnancy.
  • Incorrect coding of associated conditions or complications.
  • Lack of clarity regarding antibiotic use and safety.

Specialty Focus

Medical Specialties

Obstetrics and Gynecology

Documentation Requirements

Detailed clinical notes including symptoms, diagnostic tests, and treatment plans.

Common Clinical Scenarios

Patients presenting with pelvic pain and fever during the first trimester.

Billing Considerations

Consideration of the impact of infections on pregnancy outcomes and the need for safe antibiotic therapy.

Maternal-Fetal Medicine

Documentation Requirements

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

Common Clinical Scenarios

Management of infections in high-risk pregnancies, including those with previous complications.

Billing Considerations

Close monitoring of both maternal and fetal health due to the potential impact of infections.

Coding Guidelines

Inclusion Criteria

Use O23.521 When
  • According to ICD
  • 10 coding guidelines, specific codes must be used to indicate the trimester of pregnancy
  • Accurate documentation of the diagnosis, treatment, and any complications is essential for proper coding
  • Coders should also be aware of the guidelines regarding the use of combination codes for infections

Exclusion Criteria

Do NOT use O23.521 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

99213CPT Code

Established patient office visit, level 3

Clinical Scenario

Used for follow-up visits after diagnosis of salpingo-oophoritis.

Documentation Requirements

Documentation of symptoms, treatment response, and any changes in condition.

Specialty Considerations

Obstetricians should ensure that all relevant pregnancy details are included.

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 salpingo-oophoritis, which helps in better tracking and management of pregnancy-related infections.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of obstetric conditions, including salpingo-oophoritis, which helps in better tracking and management of pregnancy-related infections.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of obstetric conditions, including salpingo-oophoritis, which helps in better tracking and management of pregnancy-related infections.

Resources

Clinical References

  • •
    CDC Guidelines for Treating STIs in Pregnancy

Coding & Billing References

  • •
    CDC Guidelines for Treating STIs in Pregnancy

Frequently Asked Questions

What are the common symptoms of salpingo-oophoritis in pregnancy?

Common symptoms include pelvic pain, fever, abnormal vaginal discharge, and sometimes nausea or vomiting. It is important for pregnant patients to report these symptoms promptly to their healthcare provider.