2025 ICD-10-CM code O63.1
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Obstetrics - Complications of labor and delivery (O60-O77) Chapter 15: Pregnancy, childbirth and the puerperium (O00-O9A) Feed
Prolonged second stage of labor.
Modifiers are not applicable to ICD-10 codes.
Medical necessity for interventions during a prolonged second stage of labor is established based on assessment of maternal and fetal well-being.Factors such as prolonged pushing time, fetal distress (indicated by abnormal FHR patterns), maternal exhaustion, and failure to progress despite appropriate interventions justify the medical necessity for instrumental delivery or Cesarean section.
The obstetrician's responsibility includes monitoring maternal and fetal well-being throughout labor, assessing the progress of labor, determining if the second stage is prolonged, and implementing appropriate interventions such as oxytocin augmentation, instrumental delivery (forceps or vacuum), or cesarean section as clinically indicated.Postpartum care and management of potential complications are also part of their clinical responsibilities.
In simple words: This code means the second stage of labor (pushing) lasted too long.For first-time moms, this is more than three hours; for moms who've had babies before, it's more than two hours.Labor that takes too long can be risky for both the mom and the baby.
This code signifies a prolonged second stage of labor, defined as the period from complete cervical dilation (10 cm) to fetal delivery.Prolongation is determined by the time elapsed in the active pushing phase; exceeding three hours for first-time mothers (nulliparous) and two hours for subsequent deliveries (multiparous) with or without an epidural, respectively. This condition can increase the risk of maternal and fetal complications.
Example 1: A 35-year-old nulliparous woman with an epidural experiences a prolonged second stage of labor lasting 4 hours.She eventually delivers vaginally with the assistance of forceps due to fetal distress., A 28-year-old multiparous woman without an epidural experiences a prolonged second stage lasting 1.5 hours.She delivers vaginally without assistance., A 40-year-old nulliparous woman with a history of previous cesarean section develops a prolonged second stage of labor exceeding 3 hours with an epidural. A decision is made to proceed with a repeat cesarean section due to lack of progress and signs of fetal distress.
Detailed documentation should include the timing of complete cervical dilation, the start and duration of the active pushing phase,maternal vital signs, fetal heart rate monitoring (FHR) tracing, the use of any pain medication, any interventions used (e.g., oxytocin, forceps, vacuum), the mode of delivery, and any complications encountered during or after delivery (e.g., postpartum hemorrhage, perineal lacerations, infection).
** Accurate coding of prolonged second stage of labor requires careful consideration of the clinical context, including the parity of the mother, the use of epidural analgesia, and any maternal or fetal complications.The definition of "prolonged" may vary slightly depending on institutional guidelines but generally aligns with the established thresholds.
- Revenue Code: Revenue codes will vary depending on the specific services rendered and the healthcare payer.Consultation with a medical billing specialist is recommended.
- RVU: RVUs are not directly associated with ICD-10 codes.Reimbursement is determined by the procedures and services performed and the associated CPT or HCPCS codes.
- Global Days: Not applicable to ICD-10 codes.
- Payment Status: Active
- Modifier TC rule: Not applicable to ICD-10 codes.
- Fee Schedule: Not applicable to ICD-10 codes.
- Specialties:Obstetrics and Gynecology
- Place of Service:Inpatient Hospital, Birthing Center, Ambulatory Surgical Center