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2025 ICD-10-CM code O03.39

Incomplete spontaneous abortion with other complications.

Use additional code(s) to specify the associated complication(s) (e.g., sepsis, renal failure). Only use codes from Chapter 15 on the maternal record, not the newborn record.

Medical necessity for this code is established by the diagnosis of an incomplete spontaneous abortion with other complications. Treatment provided must be related to managing both the incomplete abortion and the associated complications.

The physician is responsible for diagnosing the incomplete abortion and associated complications, managing the patient's condition (which might include procedures like dilation and curettage), and providing appropriate follow-up care.

IMPORTANT:For specific complications following incomplete spontaneous abortion, use codes O03.30-O03.38. For incomplete spontaneous abortion without complications, use O03.4.To specify weeks of gestation, use additional code from category Z3A.

In simple words: This code indicates a miscarriage where not all tissue has passed from the womb and other medical problems have developed.

This code signifies an incomplete spontaneous abortion, where some products of conception remain in the uterus, accompanied by additional complications not specifically classified under other O03 subcategories.These complications could include, but are not limited to, shock, renal failure, metabolic disorders, damage to pelvic organs, other venous complications, cardiac arrest, sepsis, or urinary tract infection.

Example 1: A pregnant woman in her first trimester presents with vaginal bleeding and abdominal pain. Ultrasound confirms an incomplete miscarriage with retained products of conception. She also develops a urinary tract infection following the miscarriage, requiring antibiotic treatment. Code O03.39 and N39.0 are assigned., A woman in her second trimester experiences an incomplete miscarriage and subsequently develops shock due to blood loss. She receives intravenous fluids and a blood transfusion. Code O03.39 and R57.1 are assigned., A pregnant woman experiences an incomplete miscarriage at home and is brought to the emergency room. Upon examination, it's found she has some retained products of conception and is also experiencing acute renal failure. This is coded as O03.39 and N17.9.

Documentation should include ultrasound findings confirming incomplete abortion, details of the associated complication(s), treatment provided, and any relevant lab results.

** ICD-10-CM O03.39 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. As of December 01, 2024, this code is clinically valid. Refer to iFrameAI for more specific coding guidance related to individual cases.

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