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2025 ICD-10-CM code O03.9

Complete or unspecified spontaneous abortion without complication; Miscarriage without complication.

Refer to the official ICD-10-CM coding guidelines for detailed instructions. Ensure that all products of conception are expelled from the uterus to apply code O03.9. If any complications arise, a separate code to specify those conditions should be added.

Medical necessity for coding O03.9 rests on the accurate diagnosis of a complete spontaneous abortion without complications. The diagnosis necessitates confirmation of the pregnancy loss, assessment of the gestational age, and exclusion of any other underlying medical conditions contributing to the miscarriage.

The clinical responsibility for coding O03.9 falls upon the healthcare provider managing the patient's pregnancy and the subsequent miscarriage. This includes confirming the diagnosis through physical examination, ultrasound imaging, and potentially laboratory testing of hCG levels. The physician or other qualified healthcare professional will also provide appropriate counseling and care for the patient.

IMPORTANT:Related codes may include O03.4 (Incomplete spontaneous abortion without complication) if some products of conception remain in the uterus, O02.1 (Embryonic demise) for early fetal death, and O02.0 (Anembryonic pregnancy) for blighted ovum. Codes from category Z3A (Weeks of gestation) can be used additionally to specify the gestational age at the time of the miscarriage.

In simple words: This code means a miscarriage happened without any problems.The baby was lost before 20 weeks of pregnancy, and everything related to the pregnancy came out of the body naturally. There were no additional health issues for the mother.

This ICD-10-CM code classifies a complete or unspecified spontaneous abortion (miscarriage) that occurs without any complications.It signifies the premature expulsion of a non-viable fetus from the uterus before the 20th week of gestation, without any deliberate interference or intervention. The pregnancy loss is complete, meaning all products of conception have been expelled from the uterus.The absence of complications is crucial; this code is not used if there were any associated conditions or complications arising from the miscarriage.

Example 1: A 30-year-old woman presents to the emergency department with vaginal bleeding and abdominal cramping.A pelvic examination and ultrasound reveal a complete spontaneous abortion. The products of conception have been completely expelled. No additional medical intervention is required., A 25-year-old woman experiences vaginal bleeding at home. After consulting with her healthcare provider, she is diagnosed with a complete spontaneous abortion.The patient reports complete expulsion of pregnancy products at home, and no further treatment is necessary., A 35-year-old woman is found to have a complete spontaneous abortion during a routine prenatal visit. Ultrasound confirms the absence of retained products of conception, and her care involves monitoring, and appropriate counseling following the miscarriage.

Documentation should include a detailed history of the patient’s pregnancy, including gestational age at the time of the miscarriage.Clinical findings should detail the symptoms (vaginal bleeding, cramping), and the results of any diagnostic testing performed, including ultrasound findings to confirm the complete expulsion of pregnancy tissue.Confirmation of the diagnosis, especially in cases where products of conception are expelled at home, may include physical exam findings, beta-hCG levels monitoring to decline to zero. Counseling or referral notes should also be documented.

** While this code indicates a complete miscarriage without complications, the patient may still require follow-up care for monitoring of hCG levels, and to address psychological support after the loss of the pregnancy.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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