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v1.0.0
ICD-10 Guide
ICD-10 CodesO34.40

O34.40

Billable

Maternal care for other abnormalities of cervix, unspecified trimester

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

Code Description

ICD-10 O34.40 is a billable code used to indicate a diagnosis of maternal care for other abnormalities of cervix, unspecified trimester.

Key Diagnostic Point:

Maternal care for abnormalities of the cervix encompasses a variety of conditions that may affect pregnancy outcomes. These abnormalities can include cervical incompetence, cervical polyps, or other structural anomalies that may not be specified. Such conditions can lead to complications such as preterm labor or miscarriage. In cases where there is a history of previous cesarean deliveries or uterine scarring, careful monitoring and management are crucial. The cervix plays a vital role in maintaining pregnancy, and any abnormalities can necessitate interventions such as cervical cerclage or increased surveillance. The unspecified trimester designation indicates that the condition may arise at any point during the pregnancy, requiring ongoing assessment and tailored care strategies to ensure maternal and fetal well-being.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in documentation of cervical abnormalities
  • Need for detailed patient history including previous surgeries
  • Potential for multiple concurrent obstetric conditions
  • Variations in treatment protocols based on specific abnormalities

Audit Risk Factors

  • Inadequate documentation of cervical abnormalities
  • Failure to specify the trimester of care
  • Lack of correlation between diagnosis and treatment provided
  • Inconsistent use of terminology in clinical notes

Specialty Focus

Medical Specialties

Obstetrics and Gynecology

Documentation Requirements

Detailed documentation of cervical examinations, findings, and any interventions performed.

Common Clinical Scenarios

Management of cervical incompetence, monitoring of cervical polyps during pregnancy.

Billing Considerations

Ensure that all relevant patient history, including previous surgeries and complications, is documented to support the diagnosis.

Maternal-Fetal Medicine

Documentation Requirements

Comprehensive documentation of high-risk factors, including previous cesarean deliveries and uterine scarring.

Common Clinical Scenarios

Assessment and management of high-risk pregnancies with cervical abnormalities.

Billing Considerations

Focus on the implications of cervical abnormalities on fetal health and the need for specialized monitoring.

Coding Guidelines

Inclusion Criteria

Use O34.40 When
  • Follow the official ICD
  • CM guidelines for obstetric coding, ensuring that the diagnosis is supported by clinical documentation
  • Pay attention to the specific criteria for coding abnormalities of the cervix and the importance of trimester classification

Exclusion Criteria

Do NOT use O34.40 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

59400CPT Code

Obstetric care including antepartum care, delivery, and postpartum care

Clinical Scenario

Used for comprehensive obstetric care in patients with cervical abnormalities.

Documentation Requirements

Complete documentation of all visits, assessments, and interventions related to the pregnancy.

Specialty Considerations

Obstetricians should ensure that all aspects of care are documented to support billing.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of cervical abnormalities, improving the accuracy of diagnoses and treatment plans. This specificity aids in better patient management and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of cervical abnormalities, improving the accuracy of diagnoses and treatment plans. This specificity aids in better patient management and resource allocation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of cervical abnormalities, improving the accuracy of diagnoses and treatment plans. This specificity aids in better patient management and resource allocation.

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 O34.40?

Documentation should include specific findings related to the cervical abnormality, any interventions performed, and the patient's obstetric history, including previous cesarean deliveries or complications.