ICD-10 Coding for Supervision of Pregnancy(O09.522, O09.211)
Complete ICD-10-CM coding and documentation guide for Supervision of Pregnancy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Supervision of Pregnancy
O09Primary Range
Supervision of high-risk pregnancy
This range includes codes for the supervision of pregnancies with various high-risk factors, such as history of preterm labor or stillbirth.
Weeks of gestation
These codes are used to specify the gestational age of the pregnancy, which is critical for accurate documentation and coding.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| O09.522 | Supervision of pregnancy with history of stillbirth | Use for prenatal visits when there is a documented history of stillbirth. |
|
| O09.211 | Supervision of pregnancy with history of preterm labor, second trimester | Use for prenatal visits in the second trimester with a history of preterm labor. |
|
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 supervision of pregnancy with history of stillbirth
Essential facts and insights about Supervision of Pregnancy
Primary ICD-10-CM Codes for supervision of pregnancy
Decision Criteria
documentation Criteria
- History of stillbirth must be explicitly documented with gestational age.
Applicable To
- History of intrauterine fetal demise at ≥20 weeks
Excludes
- Current pregnancy with complications (O10-O16)
Clinical Validation Requirements
- Documented history of stillbirth at ≥20 weeks
- Trimester of current pregnancy
Code-Specific Risks
- Incorrectly using this code during delivery encounters.
Coding Notes
- Ensure documentation includes specific details about the history of stillbirth and current gestational age.
O09.211 - Supervision of pregnancy with history of preterm labor, second trimester
Use for prenatal visits in the second trimester with a history of preterm labor.
Applicable To
- History of preterm labor in previous pregnancies
Excludes
- Current pregnancy with preterm labor (O60)
Clinical Validation Requirements
- Documented history of preterm labor
- Current trimester
Coding Notes
Ensure documentation includes specific details about the history of preterm labor and current gestational age.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Supervision of Pregnancy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code O09.522.
Impact
Clinical: Inaccurate clinical records., Regulatory: Non-compliance with ICD-10 documentation standards., Financial: Potential claim denials or reduced reimbursement.
Mitigation Strategy
Always include gestational age and trimester in documentation., Use templates to ensure completeness.
Impact
Reimbursement: Incorrect coding can lead to claim denials., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate data on delivery outcomes.
Mitigation Strategy
Use O80 or appropriate complication codes for delivery encounters.
Impact
Incomplete documentation of high-risk factors can lead to audit findings.
Mitigation Strategy
Use detailed templates and ensure all high-risk factors are documented.
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 Supervision of Pregnancy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Supervision of Pregnancy
Use these documentation templates to ensure complete and accurate documentation for Supervision of Pregnancy. These templates include all required elements for proper coding and billing.
High-Risk Pregnancy Supervision
Specialty: ObstetricsRequired Elements
- History of present pregnancy
- Risk factors
- Current complications
- Physical exam findings
- Plan of care
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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