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v1.0.0
ICD-10 Guide
ICD-10 CodesO23.91

O23.91

Billable

Unspecified genitourinary tract infection in pregnancy, first trimester

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

Code Description

ICD-10 O23.91 is a billable code used to indicate a diagnosis of unspecified genitourinary tract infection in pregnancy, first trimester.

Key Diagnostic Point:

Genitourinary tract infections (UTIs) during pregnancy are common and can pose significant risks to both the mother and fetus if not properly managed. In the first trimester, these infections may present with nonspecific symptoms such as dysuria, frequency, and urgency. The diagnosis of an unspecified genitourinary tract infection in pregnancy requires careful clinical evaluation, including urinalysis and urine culture to identify the causative organism. Common pathogens include Escherichia coli and Group B Streptococcus. Treatment typically involves the use of antibiotics that are safe for use during pregnancy, such as nitrofurantoin or amoxicillin, while avoiding those contraindicated, like tetracyclines and fluoroquinolones. Early identification and treatment are crucial to prevent complications such as pyelonephritis, which can lead to preterm labor and low birth weight. Coders must ensure accurate documentation of symptoms, laboratory findings, and treatment plans to support the use of this code.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in symptoms and presentation of UTIs in pregnancy
  • Need for laboratory confirmation of infection
  • Differentiation from other conditions such as asymptomatic bacteriuria
  • Potential for complications affecting coding and treatment

Audit Risk Factors

  • Inadequate documentation of symptoms and laboratory results
  • Failure to specify the type of infection if known
  • Incorrect coding of antibiotic treatments
  • Lack of follow-up documentation on treatment outcomes

Specialty Focus

Medical Specialties

Obstetrics and Gynecology

Documentation Requirements

Detailed documentation of patient history, presenting symptoms, urinalysis results, and prescribed treatments.

Common Clinical Scenarios

A pregnant patient presents with dysuria and frequency; urinalysis shows bacteria, leading to a diagnosis of UTI.

Billing Considerations

Consideration of antibiotic safety in pregnancy and potential side effects.

Maternal-Fetal Medicine

Documentation Requirements

Comprehensive documentation for high-risk pregnancies, including maternal health history and fetal monitoring.

Common Clinical Scenarios

A patient with a history of recurrent UTIs presents in the first trimester; close monitoring is required.

Billing Considerations

Increased vigilance for complications such as pyelonephritis and its impact on fetal health.

Coding Guidelines

Inclusion Criteria

Use O23.91 When
  • Follow ICD
  • CM guidelines for obstetric coding, ensuring that the diagnosis is supported by clinical documentation and that the trimester is accurately recorded

Exclusion Criteria

Do NOT use O23.91 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

87086CPT Code

Urine culture, bacterial

Clinical Scenario

Ordered when a UTI is suspected in a pregnant patient.

Documentation Requirements

Document the reason for the culture and any prior treatments.

Specialty Considerations

Ensure that the culture results are linked to the diagnosis for accurate coding.

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 tracking.

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 tracking.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of obstetric conditions, improving the accuracy of diagnoses and treatment tracking.

Resources

Clinical References

  • •
    CDC Guidelines for Treating UTIs in Pregnancy

Coding & Billing References

  • •
    CDC Guidelines for Treating UTIs in Pregnancy

Frequently Asked Questions

What are the common symptoms of a genitourinary tract infection in pregnancy?

Common symptoms include dysuria, increased urinary frequency, urgency, and sometimes flank pain or fever. It's important to differentiate these from normal pregnancy symptoms.