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ICD-10 Guide
ICD-10 CodesO34.539

O34.539

Billable

Maternal care for retroversion of gravid uterus, unspecified trimester

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

Code Description

ICD-10 O34.539 is a billable code used to indicate a diagnosis of maternal care for retroversion of gravid uterus, unspecified trimester.

Key Diagnostic Point:

Retroversion of the gravid uterus refers to a condition where the uterus is tilted backward instead of its normal forward position. This condition can occur during pregnancy and may lead to various complications, including discomfort, urinary issues, and potential obstruction of the birth canal during labor. Maternal care for this condition involves careful monitoring and management, especially in women with a history of pelvic organ abnormalities, previous cesarean deliveries, or uterine scarring. These factors can complicate the pregnancy and delivery process, necessitating a multidisciplinary approach to care. The management may include physical therapy, positional changes, and in some cases, surgical intervention if the retroversion leads to significant complications. It is crucial for healthcare providers to document the specifics of the condition, including the trimester of pregnancy, to ensure appropriate care and coding.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and symptoms of retroversion
  • Need for detailed documentation of previous obstetric history
  • Potential for associated complications requiring additional coding
  • Differentiation from other pelvic organ abnormalities

Audit Risk Factors

  • Inadequate documentation of the condition's impact on pregnancy
  • Failure to note previous cesarean or uterine scarring
  • Misclassification of the trimester of pregnancy
  • Lack of clarity on associated symptoms or complications

Specialty Focus

Medical Specialties

Obstetrics and Gynecology

Documentation Requirements

Detailed obstetric history, including previous surgeries and complications, must be documented. Providers should note any symptoms related to retroversion and their management.

Common Clinical Scenarios

A pregnant patient presents with pelvic pain and urinary frequency; upon examination, retroversion is diagnosed. Management may include monitoring and patient education.

Billing Considerations

Coders should ensure that all relevant history is captured, particularly in cases of previous cesarean sections or uterine scarring, which may influence delivery options.

Maternal-Fetal Medicine

Documentation Requirements

High-risk pregnancy documentation must include detailed assessments of the retroversion's impact on fetal well-being and maternal health.

Common Clinical Scenarios

A patient with a history of uterine scarring presents with retroversion and is monitored closely for potential complications.

Billing Considerations

High-risk scenarios may require additional codes for associated conditions, and careful tracking of maternal and fetal health is essential.

Coding Guidelines

Inclusion Criteria

Use O34.539 When
  • According to ICD
  • 10 coding guidelines, it is essential to document the specific trimester and any associated complications
  • Coders should ensure that the diagnosis aligns with the clinical documentation and that all relevant history is included

Exclusion Criteria

Do NOT use O34.539 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

59400CPT Code

Obstetrical care including antepartum care, delivery, and postpartum care

Clinical Scenario

Used for comprehensive obstetric care in patients with retroversion, ensuring all aspects of care are documented.

Documentation Requirements

Complete documentation of all prenatal visits, delivery details, and postpartum follow-up is required.

Specialty Considerations

Obstetricians should ensure that any complications related to retroversion are noted in the patient's record.

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 retroversion of the gravid uterus. This specificity aids in better tracking of maternal health outcomes and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of obstetric conditions, including retroversion of the gravid uterus. This specificity aids in better tracking of maternal health outcomes and resource allocation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of obstetric conditions, including retroversion of the gravid uterus. This specificity aids in better tracking of maternal health outcomes 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 is the significance of coding O34.539?

Coding O34.539 is significant as it captures the maternal care for retroversion of the gravid uterus, which can impact pregnancy management and delivery. Accurate coding ensures appropriate care and resource allocation.