In simple words: This code indicates that a pregnant woman is receiving care because her uterus is tilted backwards, and the trimester of pregnancy is not specified.

This code describes the care a pregnant woman receives due to the tilting of the uterus backwards towards the rectum, during an unspecified stage of pregnancy.It is used when this condition necessitates hospitalization, other obstetric care, or cesarean delivery before labor begins.

Example 1: A pregnant woman presents with discomfort and difficulty urinating. Upon examination, a retroverted gravid uterus is diagnosed, but the specific trimester is not documented in the medical record. The physician provides care and recommendations for managing the condition. O34.539 is used because the trimester isn't specified., A woman in her second trimester with a known retroverted uterus experiences increasing pain. She seeks medical attention, and the physician determines the condition requires further monitoring and management throughout the pregnancy. However, during the record keeping, the trimester is accidentally omitted.The coder uses O34.539 as the trimester isn't specified on the record., A pregnant woman undergoes a routine ultrasound, and a retroverted gravid uterus is incidentally discovered.She's asymptomatic and the condition doesn't require specific intervention beyond routine prenatal care. When documenting this encounter, the trimester is not specified. O34.539 is applied to denote the retroverted uterus with an unspecified trimester.

Documentation should include a clear diagnosis of retroversion of the gravid uterus, details of associated signs and symptoms if present, trimester of pregnancy (if known - a Z3A code should also be used), any interventions or treatments provided, and any planned management for the condition.

** This code is to be used only on the maternal record, never on the newborn record. This code should not be used if the trimester is documented.