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2025 ICD-10-CM code O03.4

Incomplete spontaneous abortion without complication.

Codes from Chapter O are for use only on maternal records, never on newborn records.Additional code from category Z3A may be used to specify the week of gestation.

Medical necessity is established by the presence of an incomplete spontaneous abortion with retained products of conception that pose a risk to the patient's health.This could include heavy bleeding, infection, or ongoing cramping.

Obstetrician/Gynecologist

IMPORTANT:Excludes1: continuing pregnancy in multiple gestation after abortion of one fetus or more (O31.1-, O31.3-)

In simple words: This code means a miscarriage where some pregnancy tissue is still in the uterus, but there are no other problems.

This code is used to classify an incomplete spontaneous abortion where the pregnancy has ended prematurely, and some products of conception remain in the uterus, but there are no associated complications.

Example 1: A 25-year-old woman presents with vaginal bleeding and cramping at 8 weeks gestation.Ultrasound confirms an incomplete abortion with retained products of conception.Manual removal of the retained tissue is performed., A 30-year-old woman experiences a miscarriage at 10 weeks gestation.She presents with heavy vaginal bleeding and some tissue passed.A pelvic exam reveals retained products of conception requiring a D&C procedure., A 40-year-old woman reports vaginal bleeding and lower abdominal pain at 12 weeks gestation. An ultrasound shows an incomplete abortion. Medical management is chosen (Misoprostol) leading to the expulsion of remaining pregnancy tissue.

* Detailed history of present illness, including onset, duration, and character of symptoms.* Results of pelvic examination.* Ultrasound findings documenting the presence of retained products of conception and the gestational age.* Documentation of the procedure performed (e.g., D&C, medical management).* Any complications encountered during the procedure or treatment.

** This code should only be used when there are no other complications associated with the incomplete spontaneous abortion. If any complications are present, those should be coded separately in addition to O03.4.The appropriate gestational age should be documented.

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