2025 ICD-10-CM code O40.9
Polyhydramnios, unspecified trimester.
Seventh characters are applicable to specify the fetus affected when there are multiple gestations.Use additional code, if applicable, from category Z3A, Weeks of gestation, to identify the specific week of the pregnancy, if known.
Medical necessity for the diagnosis and management of polyhydramnios is based on the potential risks to both the mother and fetus, such as preterm labor, fetal malpresentation, and cord prolapse.Treatment is medically necessary to mitigate these risks and optimize pregnancy outcomes.Medical necessity should be supported by the documentation of the severity of the condition, associated complications, and treatment plan.
Obstetricians and other healthcare professionals managing pregnancies are responsible for diagnosing and managing polyhydramnios.They monitor amniotic fluid levels, assess the underlying cause, and provide appropriate care to both the mother and fetus.
In simple words: This code indicates an excess of amniotic fluid during pregnancy at an unspecified time during the pregnancy.
Polyhydramnios is a condition characterized by excessive amniotic fluid surrounding the fetus during pregnancy.The trimester in which this condition occurs is unspecified. This code is used only on maternal records, not newborn records.
Example 1: A pregnant woman in her second trimester presents with an unusually large abdomen and discomfort. Ultrasound reveals excessive amniotic fluid consistent with polyhydramnios. The trimester is documented and O40.9 is coded.As the pregnancy is in the second trimester Z3A.16 is added., A pregnant woman with poorly controlled diabetes develops polyhydramnios in her third trimester. The polyhydramnios is documented, however, because of maternal diabetes mellitus complicating pregnancy, childbirth and the puerperium (O24.4-) is reported first, followed by O40.9. The specific week of pregnancy Z3A.30 is also reported., A pregnant woman with a twin pregnancy is diagnosed with polyhydramnios affecting one fetus. O40.1- is reported, followed by the appropriate 7th character for the affected fetus, e.g., O40.1X1.The specific week of pregnancy Z3A.20 is also reported.
Documentation should include ultrasound findings confirming excessive amniotic fluid, along with the trimester of pregnancy, any associated symptoms or underlying conditions.The specific week of pregnancy should be documented when known. Any fetal involvement and related complications should be documented. Any treatment or management plan should be documented. Documentation needs to include clinical indicators supporting the diagnosis and how it impacts the patient's care.
- Payment Status: Active
- Specialties:Obstetrics, Maternal-Fetal Medicine
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Independent Clinic, Federally Qualified Health Center