2025 ICD-10-CM code Z3A.16
16 weeks gestation of pregnancy.
The medical necessity for using Z3A.16 is to document the pregnancy status at a specific gestational age, which is crucial for guiding appropriate prenatal care, monitoring fetal development, and planning for delivery.
The clinician's responsibility when using Z3A.16 includes accurate assessment and documentation of the gestational age, providing appropriate prenatal care and counseling, and ordering necessary tests or referrals based on the patient's individual needs and risk factors.
- Chapter 21: Factors Influencing Health Status and Contact with Health Services (Z00-Z99)
- Persons encountering health services in circumstances related to reproduction (Z30-Z3A)
In simple words: This code indicates a pregnancy at 16 weeks.
This code is used to indicate a pregnancy at 16 weeks gestation. It is typically used during encounters for routine prenatal care or other related health services.
Example 1: A pregnant woman at 16 weeks gestation presents for a routine prenatal check-up. The physician documents the encounter using Z3A.16., A pregnant woman at 16 weeks gestation presents to the emergency department with mild abdominal pain. After examination, it is determined that the pain is likely related to round ligament pain, a common pregnancy discomfort. The physician documents the pregnancy status using Z3A.16 along with the appropriate code for the abdominal pain., A pregnant woman at 16 weeks gestation undergoes a routine ultrasound for fetal anomaly screening. The physician documents the pregnancy status using Z3A.16 along with the appropriate code for the ultrasound procedure.
Documentation should include the estimated gestational age based on the last menstrual period, ultrasound findings, or other clinical data.Any associated signs, symptoms, or complications related to the pregnancy should also be documented.
** Z3A.16 should be used as a secondary code to the primary reason for the encounter, unless the encounter is solely for pregnancy-related care.
- Specialties:Obstetrics, Family Medicine, Midwifery
- Place of Service:Office, Outpatient Hospital, Inpatient Hospital