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 with no abnormalities. You must confirm that the mother is receiving antepartum care and there are (thus far) no complications or abnormalities of the organs and soft tissues of the pelvis causing an obstruction or complication.
If the presence of a scar from a previous C-section is causing an obstruction or complication—such as requiring hospitalization, specific obstetric care, or cesarean delivery before the onset of labor—use O34.21- Maternal care for scar from previous cesarean delivery. This is also is correct code for postpartum care if the patient has had a C-section delivery.
Note that the sixth character in the above code indicates the type of scar. You should 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
O34.21- can be used for both the antepartum and postpartum care of the mother.
If the patient has a scar that is causing an obstruction or care beyond that is considered to be normal, the visit generally would not be considered “routine;” therefore, I recommend not coding O34.21- with Z34.- normal pregnancy.
If the care rendered is routine, and the C-section scar is not causing a complication or obstruction, the provider should report the history of a previous C-section scar with Z98.891 and the primary Z34.- diagnosis code.