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v1.0.0
ICD-10 Guide
ICD-10 CodesO34.71

O34.71

Billable

Maternal care for abnormality of vulva and perineum, first trimester

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

Code Description

ICD-10 O34.71 is a billable code used to indicate a diagnosis of maternal care for abnormality of vulva and perineum, first trimester.

Key Diagnostic Point:

O34.71 refers to maternal care for abnormalities of the vulva and perineum during the first trimester of pregnancy. This condition may include congenital malformations, acquired lesions, or infections affecting the vulvar and perineal regions. Such abnormalities can lead to complications during pregnancy, including discomfort, pain, and potential risks during delivery, especially in women with a history of cesarean sections or uterine scarring. Careful monitoring and management are essential to ensure maternal and fetal well-being. Healthcare providers must assess the severity of the abnormality, consider the implications for delivery, and provide appropriate interventions. This may involve multidisciplinary care, including obstetricians, gynecologists, and maternal-fetal medicine specialists, to address both the maternal condition and any potential fetal implications.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation of vulvar and perineal abnormalities
  • Need for detailed documentation of previous obstetric history, including cesarean sections
  • Potential for overlapping diagnoses requiring careful differentiation
  • Variations in treatment protocols based on the type of abnormality

Audit Risk Factors

  • Inadequate documentation of the nature and severity of the abnormality
  • Failure to document previous obstetric history, including cesarean deliveries
  • Misclassification of the abnormality leading to incorrect coding
  • Lack of clear treatment plans or follow-up care documentation

Specialty Focus

Medical Specialties

Obstetrics and Gynecology

Documentation Requirements

Detailed clinical notes describing the abnormality, treatment plans, and any interventions performed.

Common Clinical Scenarios

Management of vulvar varicosities, lichen sclerosus, or perineal tears.

Billing Considerations

Consideration of how the abnormality may affect delivery method and maternal comfort.

Maternal-Fetal Medicine

Documentation Requirements

Thorough documentation of maternal-fetal interactions and any additional risks posed by the abnormality.

Common Clinical Scenarios

Monitoring high-risk pregnancies with vulvar abnormalities and assessing potential impacts on fetal health.

Billing Considerations

Focus on the implications of the abnormality for both maternal and fetal outcomes.

Coding Guidelines

Inclusion Criteria

Use O34.71 When
  • According to the official ICD
  • 10 coding guidelines, O34
  • 71 should be used when there is a documented abnormality of the vulva or perineum during the first trimester
  • Coders must ensure that the diagnosis is supported by clinical documentation and that any relevant history is included

Exclusion Criteria

Do NOT use O34.71 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 when managing a patient with vulvar abnormalities throughout pregnancy.

Documentation Requirements

Complete documentation of all prenatal visits, assessments, and any interventions.

Specialty Considerations

Obstetricians should 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 maternal conditions, including those related to vulvar and perineal abnormalities. 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 maternal conditions, including those related to vulvar and perineal abnormalities. 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 maternal conditions, including those related to vulvar and perineal abnormalities. 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 should be documented to support the use of O34.71?

Documentation should include a detailed description of the abnormality, any symptoms experienced by the patient, treatment plans, and relevant obstetric history, including previous cesarean sections or uterine scarring.