2025 ICD-10-CM code O36.92
Maternal care for fetal problem, unspecified, second trimester.
Medical necessity is established by the presence of a documented fetal problem requiring maternal intervention, observation, or treatment during the second trimester of pregnancy.
The physician providing care to the pregnant woman is responsible for documenting the fetal problem necessitating care and selecting the appropriate code.
In simple words: This code indicates that a pregnant woman is receiving care during her second trimester (weeks 14-27) because of a problem affecting the developing baby. The exact nature of the problem is not specified by this code.
This code is used for the maternal care of a pregnant woman during her second trimester (14 weeks 0 days to less than 28 weeks 0 days) due to an unspecified problem with the fetus.This code is used only on the maternal record, not the newborn's record.
Example 1: A pregnant woman at 16 weeks gestation presents with decreased fetal movement.Ultrasound reveals a fetus measuring small for gestational age. The physician provides counseling and orders additional testing. O36.92 is used to document the reason for the maternal care., A woman at 20 weeks gestation is found to have low amniotic fluid levels on ultrasound.She is admitted to the hospital for observation and further evaluation. O36.92 is applied to her record as she is receiving care related to a fetal problem (low amniotic fluid)., A pregnant woman at 25 weeks gestation has elevated maternal serum alpha-fetoprotein (MSAFP) levels.After further investigation, the cause remains unspecified. The physician continues to monitor the pregnancy closely. O36.92 would be reported for the ongoing maternal care due to the unspecified fetal problem.
Documentation should clearly specify the trimester of the pregnancy, the specific fetal problem encountered, and all diagnostic tests and treatments provided to the mother related to the fetal condition.
** It is important to differentiate O36.92 from codes related to suspected conditions that are ultimately ruled out. It’s also crucial to avoid using it when more specific codes for fetal or maternal conditions exist.This code does not apply to labor and delivery complicated by fetal stress.
- Specialties:Obstetrics, Maternal-Fetal Medicine
- Place of Service:Office, Outpatient Hospital, Inpatient Hospital