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v1.0.0
ICD-10 Guide
ICD-10 CodesO34.01

O34.01

Billable

Maternal care for unspecified congenital malformation of uterus, first trimester

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

Code Description

ICD-10 O34.01 is a billable code used to indicate a diagnosis of maternal care for unspecified congenital malformation of uterus, first trimester.

Key Diagnostic Point:

Maternal care for unspecified congenital malformation of the uterus during the first trimester involves the management and monitoring of pregnant patients who present with abnormalities in the structure of the uterus. These malformations can include conditions such as a septate uterus, unicornuate uterus, or other congenital anomalies that may affect pregnancy outcomes. During the first trimester, healthcare providers focus on assessing the implications of these malformations on the pregnancy, including risks of miscarriage, preterm labor, and complications during delivery. Care may involve ultrasound evaluations, counseling regarding potential risks, and planning for delivery, especially if a cesarean section is anticipated due to the structural abnormalities. Additionally, maternal history, including previous cesarean deliveries and uterine scarring, is crucial in determining the appropriate management plan. The goal is to ensure both maternal and fetal health while addressing any complications that may arise from the congenital malformation.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in congenital malformations and their implications for pregnancy
  • Need for detailed maternal history including previous surgeries
  • Potential for multiple coding scenarios based on associated conditions
  • Documentation requirements for high-risk pregnancies

Audit Risk Factors

  • Inadequate documentation of the congenital malformation
  • Failure to capture associated risk factors such as previous cesarean sections
  • Misclassification of the type of uterine anomaly
  • Lack of follow-up documentation for high-risk pregnancies

Specialty Focus

Medical Specialties

Obstetrics and Gynecology

Documentation Requirements

Detailed documentation of maternal history, physical examinations, and ultrasound findings related to uterine anomalies.

Common Clinical Scenarios

Management of pregnancies complicated by uterine malformations, counseling on delivery options, and monitoring for complications.

Billing Considerations

Consideration of the impact of uterine anomalies on labor and delivery, including the potential need for cesarean delivery.

Maternal-Fetal Medicine

Documentation Requirements

Comprehensive documentation of high-risk factors, including maternal age, previous obstetric history, and specific congenital malformations.

Common Clinical Scenarios

Management of high-risk pregnancies with congenital uterine anomalies, including detailed ultrasound assessments and multidisciplinary care planning.

Billing Considerations

Focus on the implications of uterine anomalies for fetal development and delivery outcomes.

Coding Guidelines

Inclusion Criteria

Use O34.01 When
  • According to the ICD
  • CM coding guidelines, this code should be used when there is a documented congenital malformation of the uterus during the first trimester
  • Coders must ensure that the documentation supports the diagnosis and that any associated conditions are also coded appropriately

Exclusion Criteria

Do NOT use O34.01 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

76801CPT Code

Ultrasound, pelvic, transabdominal

Clinical Scenario

Used to assess uterine structure in patients with suspected congenital anomalies.

Documentation Requirements

Document indications for ultrasound and findings related to uterine malformations.

Specialty Considerations

Obstetricians should collaborate with radiologists for accurate imaging interpretation.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of congenital uterine anomalies, improving the accuracy of data collection and reimbursement processes. This specificity aids in better understanding patient populations and outcomes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of congenital uterine anomalies, improving the accuracy of data collection and reimbursement processes. This specificity aids in better understanding patient populations and outcomes.

Reimbursement & Billing Impact

reimbursement processes. This specificity aids in better understanding patient populations and outcomes.

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 O34.01?

Documentation should include the specific type of congenital malformation, any associated risks, maternal history, and the management plan. Clear notes on ultrasound findings and any consultations with specialists are also important.