Back to HomeBeta

ICD-10 Coding for Abortion(O04.4, O04.1)

Complete ICD-10-CM coding and documentation guide for Abortion. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Termination of PregnancyElective AbortionSpontaneous Abortion

Quick Navigation

Related ICD-10 Code Ranges

Complete code families applicable to Abortion

O00-O08Primary Range

Pregnancy with abortive outcome

This range includes all codes related to different types of abortion, including spontaneous, elective, and those with complications.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
O04.4Medical abortion, incomplete, without complicationUse when a medical abortion is incomplete but without complications such as hemorrhage or infection.
  • Ultrasound confirmation of retained products
  • Blood loss <500mL
O04.1Incomplete medical abortion with hemorrhageUse when a medical abortion is incomplete and accompanied by significant hemorrhage.
  • Hemoglobin drop ≥2g/dL
  • Documented hemorrhage >500mL

Clinical Decision Support

Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.

Key Information: ICD-10 code for incomplete abortion

Essential facts and insights about Abortion

The ICD-10 code for incomplete medical abortion without complication is O04.4. If there is significant hemorrhage, use O04.1.

Primary ICD-10-CM Codes for abortion

O04.4
Medical abortion, incomplete, without complication
Non-billable Code

Decision Criteria

clinical Criteria

  • Retained products confirmed by ultrasound

Applicable To

  • Incomplete medical abortion without complications

Excludes

  • Complete medical abortion (O04.0)

Clinical Validation Requirements

  • Ultrasound confirmation of retained products
  • Blood loss <500mL

Code-Specific Risks

  • Incorrectly coding as complete abortion

Coding Notes

  • Ensure documentation specifies the completeness and absence of complications.
View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Encounter for elective termination of pregnancy

Z33.2
Use to indicate the encounter was for an elective abortion.

Acute posthemorrhagic anemia

D62
Use if anemia results from the hemorrhage.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Incomplete medical abortion with hemorrhage

O04.1
Presence of significant hemorrhage (>500mL) post-abortion.

Incomplete medical abortion without complication

O04.4
Absence of significant hemorrhage.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Abortion to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code O04.4.

Impact

Clinical: May lead to inappropriate follow-up care., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims.

Mitigation Strategy

Ensure ultrasound findings are documented, Link clinical findings to coding

Impact

Reimbursement: May lead to incorrect DRG assignment and affect reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of clinical data.

Mitigation Strategy

Always use the most specific code available based on documented clinical details.

Impact

Risk of audits due to insufficient documentation linking clinical findings to codes.

Mitigation Strategy

Ensure all clinical details are documented and linked to the appropriate codes.

Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.

Frequently Asked Questions

Common questions about ICD-10 coding for Abortion, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Abortion

Use these documentation templates to ensure complete and accurate documentation for Abortion. These templates include all required elements for proper coding and billing.

Incomplete medical abortion with retained products

Specialty: Obstetrics and Gynecology

Required Elements

  • Gestational age confirmation
  • Method of abortion
  • Complications noted
  • Follow-up plan

Example Documentation

Patient at 9 weeks GA underwent medical abortion. Post-procedure ultrasound confirmed retained products. Hemorrhage of 600mL managed with misoprostol.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Abortion procedure completed without complications.
Good Documentation Example
Patient at 9+2 weeks GA for elective termination. Ultrasound confirmed intrauterine pregnancy. Manual vacuum aspiration performed with incomplete evacuation noted.
Explanation
The good example provides specific details on gestational age, procedure, and complications, supporting accurate coding.

Need help with ICD-10 coding for Abortion? Ask your questions below.

Ask about any ICD-10 CM code, or paste a medical note

We build tools for
clinician happiness.

Learn More at Freed.ai
Back to HomeBeta

Built by Freed

Try Freed for free for 7 days.

Learn more

Helpful Links

How ICD 10 AI Lookup WorksContact UsPrivacy Policy