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v1.0.0
ICD-10 Guide
ICD-10 CodesO34.41

O34.41

Billable

Maternal care for other abnormalities of cervix, first trimester

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

Code Description

ICD-10 O34.41 is a billable code used to indicate a diagnosis of maternal care for other abnormalities of cervix, first trimester.

Key Diagnostic Point:

Maternal care for abnormalities of the cervix during the first trimester encompasses various conditions that may affect the cervix's structure and function, potentially impacting pregnancy outcomes. These abnormalities can include cervical incompetence, cervical polyps, or other structural anomalies that may necessitate close monitoring or intervention. In cases of previous cesarean deliveries, the presence of uterine scarring can complicate the assessment of cervical integrity. Abnormalities of pelvic organs, such as fibroids or congenital malformations, may also influence cervical health and require careful evaluation. Early identification and management of these conditions are crucial to mitigate risks such as preterm labor or miscarriage. Healthcare providers must document the nature of the cervical abnormality, any associated symptoms, and the management plan to ensure comprehensive maternal care and appropriate coding.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in types of cervical abnormalities requiring different management strategies.
  • Need for detailed documentation of previous obstetric history, including cesarean sections.
  • Potential for concurrent pelvic organ abnormalities complicating the clinical picture.
  • Variations in clinical guidelines for monitoring and intervention based on specific abnormalities.

Audit Risk Factors

  • Inadequate documentation of the specific cervical abnormality.
  • Failure to document the management plan or follow-up care.
  • Misclassification of the abnormality leading to incorrect coding.
  • Lack of clarity regarding the impact of the abnormality on the pregnancy.

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, and evaluation of previous cesarean scars.

Billing Considerations

Consideration of the patient's obstetric history and any potential impact on current pregnancy.

Maternal-Fetal Medicine

Documentation Requirements

Comprehensive documentation of high-risk factors, including detailed assessments of cervical integrity and pelvic anatomy.

Common Clinical Scenarios

Assessment of cervical length in patients with a history of preterm birth or cervical surgery.

Billing Considerations

Coordination with obstetricians for management plans tailored to high-risk patients.

Coding Guidelines

Inclusion Criteria

Use O34.41 When
  • According to official coding guidelines, O34
  • 41 should be used when there is documented maternal care for cervical abnormalities during the first trimester
  • Coders must ensure that the diagnosis is supported by clinical documentation and that any associated conditions are also coded appropriately

Exclusion Criteria

Do NOT use O34.41 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 prenatal visits, assessments, and interventions.

Specialty Considerations

Obstetricians must ensure that all aspects of care are documented to support coding.

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 maternal care documentation and reimbursement. Coders must be familiar with the nuances of the new coding system to ensure compliance and optimal reimbursement.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of cervical abnormalities, improving the accuracy of maternal care documentation and reimbursement. Coders must be familiar with the nuances of the new coding system to ensure compliance and optimal reimbursement.

Reimbursement & Billing Impact

reimbursement. Coders must be familiar with the nuances of the new coding system to ensure compliance and optimal reimbursement.

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 types of cervical abnormalities are covered under O34.41?

O34.41 covers various cervical abnormalities such as cervical incompetence, polyps, and other structural anomalies that may affect pregnancy. It is essential to document the specific abnormality and its implications for the pregnancy.