2025 ICD-10-CM code O26.852
Spotting complicating pregnancy, second trimester.
Medical necessity is established by the presence of spotting during the second trimester of pregnancy. The need for further diagnostic testing and treatment depends on the cause and severity of the spotting.
The physician is responsible for documenting the spotting, evaluating its cause, and determining the appropriate management.This may involve pelvic examination, ultrasound, fetal monitoring, and other diagnostic tests as needed.
- Chapter 15: Pregnancy, childbirth and the puerperium
- Other maternal disorders predominantly related to pregnancy (O20-O29)
In simple words: Light vaginal bleeding during the second trimester of pregnancy.
Spotting complicating pregnancy, second trimester.
Example 1: A 20-year-old pregnant woman at 18 weeks gestation presents with light pink spotting that began after intercourse. She denies abdominal pain or cramping.An ultrasound shows a normal pregnancy, and the cervix appears closed. She is reassured and instructed to refrain from intercourse for a few days., A 32-year-old woman, G2P1, at 22 weeks presents with brown spotting for the past day. She denies cramping, contractions, or other symptoms.Her vital signs and fetal heart rate are normal.A speculum exam reveals a small cervical polyp.She is advised that the spotting is likely due to the polyp and is scheduled for follow-up., A 28-year-old woman at 16 weeks gestation presents to the ER with bright red vaginal bleeding and mild cramping. An ultrasound reveals a subchorionic hematoma.She is monitored for further bleeding and instructed on activity restrictions.
Documentation should include the amount, color, and duration of the spotting, associated symptoms (e.g., pain, cramping, contractions), relevant history (e.g., recent intercourse, trauma), findings from physical exam (including pelvic exam), and results of any diagnostic studies (e.g., ultrasound).
** It is essential to differentiate spotting from more significant bleeding that may indicate a serious complication, such as placental abruption or previa.Prompt evaluation and management are crucial for optimal maternal and fetal outcomes.
- Specialties:Obstetrics and Gynecology
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Emergency Room - Hospital, other places of service.