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2025 ICD-10-CM code O41.1010

Infection of amniotic sac and membranes, unspecified trimester, during the first trimester.

This code is to be used only on the maternal record, not the newborn's.Use additional code Z3A.- to identify the specific week of gestation, if known.

Medical necessity for the diagnosis and treatment of amniotic sac infections is established by the presence of clinical signs and symptoms, confirmed by laboratory or imaging studies.Treatment is necessary to prevent serious complications for both the mother and fetus.

Diagnosis and management of infections of the amniotic sac and membranes fall under the purview of obstetricians and gynecologists (OB/GYNs). They are responsible for confirming the diagnosis, often through amniocentesis (testing the amniotic fluid) and other clinical findings, and initiating appropriate treatment, which may include antibiotics and supportive care.

In simple words: This code indicates an infection of the amniotic sac (which holds the baby) and the membranes surrounding it during the first three months of pregnancy.

Infection of amniotic sac and membranes, unspecified, first trimester, not applicable or unspecified

Example 1: A pregnant woman in her first trimester presents with fever, lower abdominal pain, and uterine tenderness.Amniocentesis confirms an infection in the amniotic fluid., A routine ultrasound examination during the first trimester reveals signs of chorioamnionitis (infection of the amniotic sac). The diagnosis is confirmed by laboratory tests., A pregnant woman with a history of premature rupture of membranes in a prior pregnancy now presents in her first trimester with signs suggesting an infection of the amniotic sac.

Documentation for O41.1010 should include: signs and symptoms (e.g., fever, pain, uterine tenderness), laboratory results confirming the presence of infection (e.g., positive amniocentesis), ultrasound findings (if applicable), and treatment plan.

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