ICD-10 Coding for Preterm Labor(O60.0, O60.1)
Complete ICD-10-CM coding and documentation guide for Preterm Labor. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Preterm Labor
O60-O60.1Primary Range
Preterm labor and delivery
This range includes codes for preterm labor with and without delivery, crucial for accurate documentation and coding.
Weeks of gestation
These codes specify the gestational age, which is necessary for coding preterm labor.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| O60.0 | Preterm labor without delivery | Use when preterm labor occurs without delivery during the encounter. |
|
| O60.1 | Preterm labor with preterm delivery | Use when preterm labor results in delivery during the encounter. |
|
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 preterm labor without delivery
Essential facts and insights about Preterm Labor
Primary ICD-10-CM Codes for preterm labor
Decision Criteria
clinical Criteria
- Presence of regular contractions and cervical dilation <3 cm.
Applicable To
- Preterm labor in second trimester
- Preterm labor in third trimester
Excludes
- False labor (O47.0-)
Clinical Validation Requirements
- Regular uterine contractions
- Cervical dilation <3 cm
- Intact membranes
Code-Specific Risks
- Incorrectly coding as O60.1 if delivery occurs.
Coding Notes
- Ensure documentation specifies no delivery occurred.
O60.1 - Preterm labor with preterm delivery
Use when preterm labor results in delivery during the encounter.
Applicable To
- Preterm labor leading to delivery
Excludes
- False labor (O47.0-)
Clinical Validation Requirements
- Regular uterine contractions
- Cervical dilation ≥3 cm
- Delivery occurs
Coding Notes
Ensure documentation specifies delivery occurred.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Preterm Labor to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code O60.0.
Impact
Clinical: Affects clinical decision-making., Regulatory: Non-compliance with coding guidelines., Financial: Potential for incorrect billing and reimbursement.
Mitigation Strategy
Always document gestational age with preterm labor codes.
Impact
Reimbursement: Incorrect coding can affect DRG assignment and reimbursement., Compliance: May lead to compliance issues with coding standards., Data Quality: Impacts the accuracy of clinical data.
Mitigation Strategy
Switch to O60.1 if delivery occurs during the encounter.
Impact
Coding preterm labor without verifying delivery status.
Mitigation Strategy
Implement checks for delivery documentation before finalizing 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 Preterm Labor, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Preterm Labor
Use these documentation templates to ensure complete and accurate documentation for Preterm Labor. These templates include all required elements for proper coding and billing.
Preterm labor without delivery
Specialty: ObstetricsRequired Elements
- Contraction frequency
- Cervical dilation
- Gestational age
- Fetal fibronectin results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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