2025 ICD-10-CM code O41
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Maternal care related to the fetus and amniotic cavity and possible delivery problems - Other disorders of amniotic fluid and membranes Pregnancy, childbirth and the puerperium Feed
Other disorders of amniotic fluid and membranes.Excludes encounter for suspected maternal and fetal conditions ruled out.
Modifiers are not applicable to ICD-10-CM codes.
Medical necessity for coding O41 is established by the presence of a clinically significant abnormality of the amniotic fluid or membranes that requires medical attention.This could include situations where fetal well-being is at risk or there is a potential for complications such as infection or preterm labor.
The clinical responsibility for this code falls on the obstetrician or maternal-fetal medicine specialist managing the pregnancy.Their duties include diagnosing the amniotic fluid/membrane abnormality, monitoring the pregnancy for potential complications, and providing appropriate management and treatment.
- Pregnancy, childbirth and the puerperium
- O30-O48 (Maternal care related to the fetus and amniotic cavity and possible delivery problems)
In simple words: This code is used when a pregnant person has a problem with the fluid (amniotic fluid) surrounding the baby or the membranes holding the fluid. This does not include cases where the doctor ruled out other possible problems with the mother or baby.
This ICD-10-CM code encompasses a range of disorders affecting the amniotic fluid and membranes during pregnancy, excluding cases where suspected maternal and fetal conditions were ultimately ruled out.It includes conditions such as oligohydramnios (reduced amniotic fluid), polyhydramnios (excess amniotic fluid), and other unspecified abnormalities of the amniotic fluid and membranes.Accurate coding requires detailed clinical documentation specifying the nature of the amniotic fluid or membrane abnormality.
Example 1: A 32-year-old pregnant woman at 36 weeks gestation presents with decreased amniotic fluid (oligohydramnios) detected during a routine ultrasound. The obstetrician orders biophysical profile testing to assess fetal well-being and discusses potential risks and management options with the patient., A 28-year-old pregnant woman at 20 weeks gestation is diagnosed with polyhydramnios (excess amniotic fluid) based on ultrasound findings. The provider monitors the pregnancy closely for potential complications such as preterm labor and performs amniocentesis to assess for fetal anomalies., A 40-year-old pregnant woman experiences premature rupture of membranes (PROM) at 30 weeks gestation.The obstetrician performs a thorough examination and initiates appropriate treatment to manage the condition and prevent infection.
Detailed documentation is crucial.This should include the gestational age at diagnosis, the method of diagnosis (e.g., ultrasound, amniocentesis), the specific nature of the amniotic fluid or membrane abnormality, any associated symptoms or findings, treatment plan, and the results of any tests performed (e.g., biophysical profile, amniocentesis).
** The seventh character (0-9) in this code can be used to specify the fetus in multiple gestations.'0' indicates unspecified or single gestation.Always refer to the complete ICD-10-CM codebook and official guidelines for the most up-to-date information and coding conventions.
- Revenue Code: Revenue codes will vary depending on the specific services provided and the payer.Consult your revenue code system for appropriate codes.
- RVU: RVUs are not directly associated with ICD-10 codes. Reimbursement is determined by factors such as place of service, provider type, and payer-specific fee schedules.
- Global Days: Not applicable to this diagnostic code.
- Payment Status: Active
- Modifier TC rule: Not applicable to this diagnostic code.
- Fee Schedule: Not applicable to this diagnostic code.
- Specialties:Obstetrics, Maternal-Fetal Medicine
- Place of Service:Office, Hospital (Inpatient and Outpatient), Ambulatory Surgical Center