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2025 ICD-10-CM code O28.3

Abnormal ultrasonic finding on antenatal screening of mother.

Code O28.3 should only be used on the maternal record, never on the newborn's record. An additional code from category Z3A should be used to identify the specific week of gestation, if known.

The medical necessity for the ultrasound itself would be determined by the clinical indication for the test (e.g., routine screening, suspected anomaly). The use of O28.3 is necessary when the ultrasound reveals an abnormal finding, regardless of the reason for the ultrasound.

The healthcare provider performing the antenatal ultrasound screening is responsible for documenting the specific abnormal finding and initiating any necessary follow-up or interventions.

In simple words: The ultrasound performed during your pregnancy showed something unusual.

This code indicates an unusual discovery during an ultrasound examination performed on a pregnant woman before the birth of her child.

Example 1: A pregnant woman in her second trimester undergoes a routine ultrasound. The sonographer identifies an unusual shape to the fetal heart. This is documented using code O28.3., During a first-trimester ultrasound, an abnormally low amount of amniotic fluid is observed. The code O28.3 is used to document this finding., An ultrasound reveals an unexpected location of the placenta in the third trimester. Code O28.3 is used to record this observation.

The documentation should include the specific abnormal findings observed during the ultrasound, the date the ultrasound was performed, and any associated diagnoses or plans for further investigation.

** This code is a general code for abnormal ultrasonic findings. More specific codes may be available to describe the particular abnormality observed. This code should not be used to describe findings that are definitively diagnostic of a specific condition. If a definitive diagnosis is made based on the ultrasound findings, the code for that diagnosis should be used instead.

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