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v1.0.0
ICD-10 Guide
ICD-10 CodesQ51.3

Q51.3

Billable

Bicornate uterus

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 Q51.3 is a billable code used to indicate a diagnosis of bicornate uterus.

Key Diagnostic Point:

A bicornate uterus is a congenital uterine anomaly characterized by a uterus that has two horns and a single cervix, resulting from incomplete fusion of the Müllerian ducts during embryonic development. This condition can lead to various reproductive complications, including infertility, recurrent pregnancy loss, and preterm labor. The bicornate uterus is classified as a type of Müllerian duct anomaly and is often diagnosed through imaging techniques such as ultrasound or MRI. Patients may present with symptoms related to menstrual irregularities or complications during pregnancy. It is essential for healthcare providers to recognize this condition to manage potential obstetric risks effectively. The diagnosis and management of a bicornate uterus require a multidisciplinary approach, often involving obstetricians, gynecologists, and reproductive endocrinologists.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and symptoms among patients
  • Need for imaging studies for accurate diagnosis
  • Potential for associated anomalies in other organ systems
  • Differentiation from other uterine anomalies (e.g., septate uterus)

Audit Risk Factors

  • Inadequate documentation of imaging studies
  • Failure to specify associated anomalies
  • Misclassification with other uterine anomalies
  • Lack of clarity in clinical notes regarding symptoms

Specialty Focus

Medical Specialties

Pediatrics

Documentation Requirements

Documentation should include detailed patient history, physical examination findings, and any imaging results. It is crucial to note any associated congenital anomalies.

Common Clinical Scenarios

Common scenarios include evaluation of adolescents with menstrual irregularities or referrals for reproductive health concerns.

Billing Considerations

Consideration of the patient's age and developmental stage is essential for accurate coding and management.

Genetics

Documentation Requirements

Genetic counseling notes should document family history, potential genetic syndromes associated with uterine anomalies, and any chromosomal evaluations performed.

Common Clinical Scenarios

Scenarios may include genetic counseling for families with a history of congenital anomalies or recurrent pregnancy loss.

Billing Considerations

Genetic implications of uterine anomalies should be discussed, especially if there are associated chromosomal abnormalities.

Coding Guidelines

Inclusion Criteria

Use Q51.3 When
  • Follow the official ICD
  • CM guidelines for coding congenital malformations, ensuring accurate documentation of the condition and any associated anomalies
  • Use additional codes as necessary to capture the full clinical picture

Exclusion Criteria

Do NOT use Q51.3 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

58150CPT Code

Hysteroscopy, diagnostic

Clinical Scenario

Used to evaluate uterine anomalies, including bicornate uterus.

Documentation Requirements

Document indications for the procedure and findings.

Specialty Considerations

Obstetricians and gynecologists should ensure proper coding based on findings.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of congenital malformations, including bicornate uterus, improving the accuracy of data collection and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of congenital malformations, including bicornate uterus, improving the accuracy of data collection and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

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 are the implications of a bicornate uterus for pregnancy?

A bicornate uterus can lead to complications such as miscarriage, preterm labor, and abnormal fetal positioning. Close monitoring and management by a healthcare provider are essential for affected individuals.