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2025 ICD-10-CM code O03.30

Unspecified complication following an incomplete spontaneous abortion. This code is used when there are complications after an incomplete miscarriage where some products of conception remain in the uterus.

Code O03.30 is used only on the maternal record, never on the newborn record. An additional code from category Z3A, Weeks of gestation, should be used to identify the specific week of the pregnancy, if known.If the specific complication following the incomplete spontaneous abortion is known, the appropriate code for that complication should be assigned instead of O03.30.

Medical necessity for the management of incomplete spontaneous abortion and subsequent complications is established by the presence of retained products of conception posing a risk to the patient's health (e.g., hemorrhage, infection). The medical record should clearly document the clinical findings that support the need for intervention.

The clinician is responsible for diagnosing and managing the complications following an incomplete miscarriage. This involves assessing the patient's clinical condition, providing appropriate treatment and follow-up care, and documenting the specific complication. If the complication is specified, a more descriptive code should be used.

In simple words: This code is used when there are complications after a miscarriage where the pregnancy tissue hasn't completely passed, and the specific complication isn't identified by other codes.

Unspecified complication following an incomplete spontaneous abortion. This code signifies a complication arising after an incomplete miscarriage, where not all products of conception have been expelled from the uterus. This is distinct from a complete abortion where all products of conception are expelled.The specific complication is not identified by this code. Additional codes may be necessary to fully describe the complication.

Example 1: A 28-year-old female presents to the emergency room with vaginal bleeding and lower abdominal pain after a confirmed miscarriage at 10 weeks gestation. Ultrasound examination shows retained products of conception. During the dilation and curettage (D&C) procedure to remove the retained tissue, the patient experiences a uterine perforation, which is a complication. The code O03.30 would be used to describe this scenario as it represents the unspecified complication following incomplete spontaneous abortion. An additional code would be needed to denote the uterine perforation., A 32-year-old female patient is diagnosed with an incomplete miscarriage at 12 weeks of gestation. She experiences persistent and heavy bleeding after the initial event.Ultrasound reveals retained products of conception, and she is admitted for a D&C. Following the procedure, she develops a post-procedural infection requiring intravenous antibiotics. O03.30 would be used, along with an additional code for the infection., A woman at 8 weeks gestation presents with cramping and bleeding.An ultrasound confirms an incomplete miscarriage.She chooses expectant management, but after a week, develops fever and chills.She returns to the clinic, and an examination reveals retained products of conception and an infection. Code O03.30 is applied along with the code for the specific infection.

Documentation should include details of the incomplete spontaneous abortion, such as gestational age, confirmation of retained products of conception (e.g., via ultrasound), and details of the unspecified complication. Any procedures performed, like a D&C, should also be documented. If the specific complication is known, it must be documented for correct coding.

** This code should not be used if the abortion was induced or if the specific complication is known. It also should not be used with codes from category O08 (Complications following abortion, miscarriage and ectopic pregnancy) on the same record.Remember to code Z3A.- weeks of gestation if known. It is important to use this code specifically when the complication is not otherwise classified.

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