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2025 ICD-10-CM code O09.611

Supervision of young primigravida, first trimester.

This code is to be used only on the maternal record, never on the newborn record.Use additional code from category Z3A, Weeks of gestation, to identify the specific week of the pregnancy, if known.

Medical necessity for this code is established by the presence of a confirmed pregnancy in a young primigravida who requires regular prenatal care to ensure the health of both the mother and the developing fetus.

The physician is responsible for providing regular prenatal care to the young primigravida, including monitoring the patient's health, assessing fetal development, ordering and interpreting diagnostic tests, providing education and counseling on pregnancy-related issues, and managing any complications that may arise.

In simple words: Medical supervision of a young woman during her first pregnancy, within the first three months.

Supervision of a young primigravida during the first trimester of pregnancy.

Example 1: A 19-year-old woman presents to her physician for her first prenatal visit at 8 weeks gestation. She has no significant medical history and her pregnancy is progressing normally. The physician provides routine prenatal care, including education on diet and exercise during pregnancy., A 25-year-old primigravida at 10 weeks gestation experiences severe morning sickness and dehydration requiring intravenous fluids. The physician manages her symptoms and monitors her condition closely., A 22-year-old primigravida is diagnosed with gestational diabetes at 12 weeks gestation. The physician initiates appropriate management, including dietary modifications, blood glucose monitoring, and insulin therapy if necessary.

Documentation should include confirmation of the pregnancy, the patient's age, gestational age (calculated from the first day of the last menstrual period), details of the prenatal visits, any complications or risk factors identified, and any treatment or interventions provided.

** A young primigravida is defined as a woman in her first pregnancy, typically younger than 35 years old. The first trimester is defined as the period from the first day of the last menstrual period up to 14 weeks 0 days.

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