ICD-10 Coding for Polyhydramnios(O40.1XX, O40.2XX, O40.3XX, O40.9XX)
Complete ICD-10-CM coding and documentation guide for Polyhydramnios. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Polyhydramnios
O40Primary Range
Polyhydramnios
This range covers all codes related to polyhydramnios, specifying trimester and fetus in multiple gestations.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| O40.1XX | Polyhydramnios, first trimester | Use when polyhydramnios is diagnosed in the first trimester. |
|
| O40.2XX | Polyhydramnios, second trimester | Use when polyhydramnios is diagnosed in the second trimester. |
|
| O40.3XX | Polyhydramnios, third trimester | Use when polyhydramnios is diagnosed in the third trimester. |
|
| O40.9XX | Polyhydramnios, unspecified trimester | Use only when trimester cannot be determined. |
|
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 polyhydramnios
Essential facts and insights about Polyhydramnios
Primary ICD-10-CM Codes for polyhydramnios
Decision Criteria
clinical Criteria
- AFI ≥25 cm or SDP ≥8 cm confirmed via ultrasound.
Applicable To
- Polyhydramnios diagnosed in the first trimester
Clinical Validation Requirements
- Ultrasound showing AFI ≥25 cm or SDP ≥8 cm
- Gestational age ≤13 weeks
Code-Specific Risks
- Incorrectly coding as unspecified trimester when first trimester is documented.
Coding Notes
- Ensure trimester is specified to avoid unspecified coding.
O40.2XX - Polyhydramnios, second trimester
Use when polyhydramnios is diagnosed in the second trimester.
Applicable To
- Polyhydramnios diagnosed in the second trimester
Excludes
- Oligohydramnios (O41.0)
- Suspected conditions ruled out (Z03.7)
Clinical Validation Requirements
- Ultrasound showing AFI ≥25 cm or SDP ≥8 cm
- Gestational age between 14 and 26 weeks
Coding Notes
Ensure trimester is specified to avoid unspecified coding.
O40.3XX - Polyhydramnios, third trimester
Use when polyhydramnios is diagnosed in the third trimester.
Applicable To
- Polyhydramnios diagnosed in the third trimester
Excludes
- Oligohydramnios (O41.0)
- Suspected conditions ruled out (Z03.7)
Clinical Validation Requirements
- Ultrasound showing AFI ≥25 cm or SDP ≥8 cm
- Gestational age ≥27 weeks
Coding Notes
Ensure trimester is specified to avoid unspecified coding.
O40.9XX - Polyhydramnios, unspecified trimester
Use only when trimester cannot be determined.
Applicable To
- Polyhydramnios without specified trimester
Excludes
- Oligohydramnios (O41.0)
- Suspected conditions ruled out (Z03.7)
Clinical Validation Requirements
- Ultrasound showing AFI ≥25 cm or SDP ≥8 cm
Coding Notes
Avoid using unspecified codes when specific trimester information is available.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Weeks of gestation
Z3A.XXDifferential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Oligohydramnios
O41.0Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Polyhydramnios to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code O40.1XX.
Impact
Clinical: May lead to inappropriate clinical decisions., Regulatory: Non-compliance with coding standards., Financial: Potential for incorrect reimbursement.
Mitigation Strategy
Always include trimester in documentation., Use templates to ensure completeness.
Impact
Reimbursement: May result in incorrect DRG assignment affecting reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Always use the specific trimester code (O40.1XX, O40.2XX, O40.3XX) when trimester is known.
Impact
Reimbursement: Can affect DRG grouping and reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Incomplete clinical data.
Mitigation Strategy
Always include Z3A code to specify gestational age.
Impact
Using unspecified codes when specific trimester is documented.
Mitigation Strategy
Implement regular audits to ensure specific trimester codes are used.
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 Polyhydramnios, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Polyhydramnios
Use these documentation templates to ensure complete and accurate documentation for Polyhydramnios. These templates include all required elements for proper coding and billing.
Polyhydramnios in a multifetal pregnancy
Specialty: ObstetricsRequired Elements
- Gestational age
- Fetus designation
- AFI/SDP measurements
- Associated conditions
- Intervention details
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Polyhydramnios? Ask your questions below.