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BETA v.3.0

2025 ICD-10-CM code O03.0

Genital tract and pelvic infection following an incomplete spontaneous abortion.

This code is used only on the maternal record, never on the newborn record.An additional code from category Z3A, Weeks of gestation, should be used to identify the specific week of pregnancy, if known.

Medical necessity is established by the presence of signs and symptoms of infection following an incomplete spontaneous abortion, requiring medical intervention to prevent further complications.

The physician is responsible for diagnosing and treating the infection, which may involve antibiotics, pain management, and monitoring for complications like sepsis.

In simple words: This code indicates an infection in the female reproductive organs or pelvic area after a miscarriage where some tissue remains.

This code describes a genital tract and pelvic infection complicating an incomplete spontaneous abortion.Examples include endometritis, oophoritis, parametritis, pelvic peritonitis, salpingitis, and salpingo-oophoritis following an incomplete spontaneous abortion.

Example 1: A 28-year-old female presents with lower abdominal pain, fever, and vaginal discharge following an incomplete spontaneous abortion diagnosed one week prior., A 35-year-old female with a history of incomplete spontaneous abortion two weeks prior is admitted to the hospital with signs of pelvic inflammatory disease., A 22-year-old female experiences an incomplete spontaneous abortion and subsequently develops endometritis requiring antibiotic treatment.

Documentation should include the diagnosis of incomplete spontaneous abortion, evidence of infection (e.g., fever, pelvic pain, abnormal vaginal discharge, laboratory results), and treatment provided.

** Excludes1: sepsis following incomplete spontaneous abortion (O03.37) and urinary tract infection following incomplete spontaneous abortion (O03.38)

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