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2025 ICD-10-CM code O36.91X4

This code describes maternal care provided during the first trimester of pregnancy due to an unspecified fetal problem, specifically for pregnancies with 4 fetuses.

The ICD-10-CM guidelines state that codes from Chapter 15 (Pregnancy, Childbirth, and the Puerperium) are assigned only to the mother's record, never the newborn's record. Additional codes like Z3A.- (Weeks of gestation) should be used to specify the week of pregnancy, if known.

Medical necessity for this code stems from the presence of a fetal problem that requires medical care for the mother during the first trimester to ensure a healthy pregnancy and delivery. The documentation must clearly support the existence of a fetal problem necessitating intervention.

The physician is responsible for monitoring both the mother and the fetuses, diagnosing any problems, and providing necessary treatment or interventions to ensure the health of both the mother and the fetuses. They must also properly document the specific fetal problem encountered.

In simple words: This code indicates a pregnant woman carrying quadruplets received medical attention during the first three months of pregnancy because of a health issue affecting at least one fetus.

Maternal care for fetal problem, unspecified, first trimester, fetus 4.This code is used when a pregnant woman receives care during her first trimester (less than 14 weeks) due to a problem with one or more of the fetuses. The specific problem is not documented, but its existence necessitates maternal care. This code applies to pregnancies with quadruplets.

Example 1: A pregnant woman in her 10th week, carrying quadruplets, is experiencing bleeding. She seeks medical attention to determine the cause and ensure the well-being of her fetuses. The exact issue is unclear at the time of visit, so O36.91X4 is used., During a routine ultrasound at 12 weeks in a quadruplet pregnancy, an anomaly is detected in one of the fetuses. The mother is admitted for further investigation and monitoring, leading to the use of O36.91X4., A woman pregnant with quadruplets has a history of preterm labor. She is under close medical supervision during her first trimester to prevent any complications. Code O36.91X4 is applied due to the increased risk and close monitoring needed, even if no specific fetal problem is yet identified.

Documentation should include details about the pregnancy, including the number of fetuses (quadruplets in this case). It should also mention the specific fetal problem and all provided treatments or interventions. Details like gestational age (confirming the first trimester) should also be clearly documented.

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