Ob-Gyn Coding Alert

Don’t miss this Excludes1 note.

A spontaneous abortion is the natural, premature expulsion of the products of conception, embryo, or non-viable fetus from the uterus. A patient can sometimes have a genital tract or pelvic infection complicating the abortion.

Currently, you should use the following ICD-9-CM codes:

• 634.00, Spontaneous abortion unspecified complicated by genital tract and pelvic infection
• 634.01, Spontaneous abortion incomplete complicated by genital tract and pelvic infection
• 634.02, Spontaneous abortion complete complicated by genital tract and pelvic infection

Once October 1, 2014 hits, you’ll revert to using the following ICD-10-CM codes:

• O03.0, Genital tract and pelvic infection following incomplete spontaneous abortion
• O03.5, Genital tract and pelvic infection following complete or unspecified spontaneous abortion

ICD-10 change: Currently, you have three codes to reflect a patient having an infection during a spontaneous abortion (634.00-634.02) specifying whether the abortion was complete, incomplete, or unspecified, but once the ICD-10 implementation date rolls around, you’ll have two options: O03.0 if the abortion was incomplete or O03.5 if the abortion was complete or unspecified.

Documentation: Here are the terms you might see in your provider’s documentation:

• Endometritis
• Oophoritis
• Parametritis
• Pelvic peritonitis
• Salpingo-oophoritis

Here’s how you’ll locate this code in the Alphabetic Index:

Abortion (complete) (spontaneous) O03.9

- complicated (by) (following) O03.80

- - endometritis O03.5

- - genital tract and pelvic infection O03.5

- - oophoritis O03.5

- - parametritis O03.5

- - pelvic peritonitis O03.5

- - salpingitis or salpingo-oophoritis O03.5

- incomplete (spontaneous) O03.4

- - complicated (by) (following) O03.30- - - endometritis O03.0

- - - genital tract and pelvic infection O03.0

- - - infection

- - - - genital tract or pelvic O03.0

- - - oophoritis O03.0

- - - parametritis O03.0

- - - pelvic peritonitis O03.0

- - - salpingitis or salpingo-oophoritis O03.0

Coder’s tips: Underneath these codes, you have an Excludes1 note that forbids you from reporting this code with sepsis following an incomplete or complete or unspecified spontaneous abortion (O03.37/O03.87) or urinary tract infection following an incomplete or complete or unspecified spontaneous abortion (O03.38/O03.88). You should also pay attention to the “includes” note for an incomplete abortion.  Any of these codes would include retained products of conception following a spontaneous abortion.