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2025 ICD-10-CM code O04

Complications following (induced) termination of pregnancy.

Weeks of gestation should be recorded with the appropriate Z3A code.

This code can be used with a 4th digit to add further specificity to the complication.

Medical necessity for this code is established by the presence of a complication directly related to the induced termination of pregnancy. The documentation must support the causal relationship between the procedure and the reported complication.

The clinician is responsible for documenting the specific complication(s) that occurred following the induced termination of pregnancy.This documentation should include the type of complication, severity, and any treatment provided.

In simple words: This code is used when there are problems after an abortion.

This code encompasses complications arising after an induced termination of pregnancy.It includes complications following medical or surgical abortions.

Example 1: A patient presents with excessive bleeding following a medical abortion. The bleeding is controlled with medication. Code O04.1 is used., A patient develops a pelvic infection after a surgical abortion. The infection is treated with antibiotics. Code O04.0 is used., A patient experiences uterine perforation during a surgical abortion requiring surgical repair. Code O04.2 is used.

Documentation should clearly specify the type of induced termination of pregnancy (medical or surgical), the date of the procedure, and a detailed description of the complication(s) encountered. Any treatment provided for the complication(s) should also be documented.

** This code is used only on the maternal record, never on the newborn record. This code excludes supervision of normal pregnancy (Z34.-), mental and behavioral disorders associated with the puerperium (F53.-), obstetrical tetanus (A34), postpartum necrosis of pituitary gland (E23.0), and puerperal osteomalacia (M83.0).It also excludes encounter for elective termination of pregnancy, uncomplicated (Z33.2) and failed attempted termination of pregnancy (O07.-).

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