Cesarean-Section Scar Coding in ICD-10
When coding a previous or current cesarean-section (C-section) scar, Z98.891 History of uterine scar from previous surgery is appropriate when the mother is receiving antepartum care and has had a previous C-section delivery. You must confirm that the mother is receiving antepartum care that is considered routine, and there are (thus far) no complications with the pregnancy.
Code O34.21- Maternal care for scar from previous cesarean delivery is correct for postpartum care if the patient has had a C-section delivery. The sixth character indicates the type of scar. Encourage your providers to be exact and describe the scar with specificity:
O34.211 Maternal care for low transverse scar from previous cesarean delivery describes care for a low transverse scar
O34.212 Maternal care for classical scar from previous cesarean delivery describes care for a vertical scar – which is the classical scar from a C-section
These codes are to used only postpartum (not antepartum) because they infer that it is the scar that requires the care.
If the visit is a postpartum visit, the clinician should know which type of scar is present and should code accordingly. Even if the clinician did not perform the delivery, the medical record should reflect where the incision was made, and that information should be readily available to the clinician.
I recommend not reporting O34.21- with Z39.2 Encounter for routine postpartum follow-up, which describes routine postpartum follow up. If the patient has a scar that requires follow up, the visit generally would not be considered “routine.”
Code Z98.891 carries an exclusion (excludes 1) stating that maternal care due to uterine scar from a previous surgery should be billed with O34.2-. Code O34.2- indicates that the C-section scar requires care, rather than the actual pregnancy, leading some to believe that Z98.891 and O34.2- should not be billed together. Some providers may argue that the scar from a previous C-section can complicate the current pregnancy, and therefore it is appropriate to use the codes together. If you bill this combination, watch closely how your payers respond.