OB/GYN

Menu

Ob/Gyn

General Documentation Considerations

ICD-10 provides additional clarity that benefits obstetrics and gynecology coding. Some of the obstetrical coding enhancements include:

ICD-10-CM also provides the ability to report the specific gestational week of pregnancy with codes from category Z3A. Gestational week codes would be reported in addition to codes for complications of pregnancy. Here is an example of the gestational week code structure:

Other considerations:

Diagnoses

Abdominal Pain
Anemia
Asthma
Chronic Obstructive Pulmonary Disease (COPD)
Complications of Surgery
Cystitis
Diabetic Mellitus
Glomerulonephritis
Genital Prolapse
Hydatidiform Mole
Multiple Gestation
Newborn
Obstetrics
Obstructed Labor
Peripheral Vascular Disease (PVD)
Phlebitis / Thrombophlebitis
Preeclampsia
Pregnancy With Diabetes
Pregnancy With Hypertension
Pregnancy / Childbirth / Puerperium
Sepsis
Ulcers / Non-Pressure Ulcer / Pressure Ulcer

ICD-9 to ICD-10 Crosswalk

The codes in these crosswalks were selected based on the most commonly used ICD-9 codes according to historical MedStar Health coding data and from professional coding associations, and are ordered by frequency of use. 

Not all the codes you need are contained in this list. For a comprehensive list of ICD-10 codes, use Diagnosis Assistant or the IMO Anywhere tool.

Code Description (ICD-9 codes are in blue)
701.0 Circumscribed scleroderma
L94.0 Localized scleroderma [morphea]
L90.0 Lichen sclerosus et atrophicus
L94.1
 Linear scleroderma
L94.3
 Sclerodactyly
V72.31 Routine gynecological exam
Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings

 * Use additional code to identify abnormal findings
Z01.419
 Encounter for gynecological examination (general) (routine) without abnormal findings

 Instructional note under codes should be as follows:

 **Use additional code:

 for screening for human papillomavirus, if applicable (Z11.51)

 for screening vaginal pap smear, if applicable (Z12.72)

 for screening vaginal pap smear, if applicable (Z12.72)
627.1 Postmenopausal bleeding
N95.0 Postmenopausal bleeding
624.9 Noninflammatory disorders of the vulva and perineum, unspedfied
N90.9 Noninflammatory disorder of vulva and perineum, unspecified
N90.0
 Mild vulvar dysplasia
N90.1
 Moderate vulvar dysplasia
N90.3
 Dysplasia of vulva, unspecified
N90.4
 Leukoplakia of vulva
N90.5
 Atrophy of vulva
N90.6
 Hypertrophy of vulva
N90.7
 Vulvar cyst
N90.810
 Female genital mutilation status, unspecified
N90.811
 Female genital mutilation status, Type I status
N90.812
 Female genital mutilation status Type II status
N90.813
 Female genital mutilation status, Type Ill status
N90.818
 Other female genital mutilation status
N90.89
 Other specified noninflammatory disorders of vulva and perineum
625.9 Female genital symptoms NOS
N94.89 Other specified conditions associated with female
N94.9 Unspecified condition associated with female genital organs and menstrual cycle
R10.2
 Pelvic and perineal pain
R19.8
 Other specified symptoms and signs involving the digestive system and abdomen
R39.9
 Unspecified symptoms and signs involving the genitourinary system
618.01 Cystocele, midline
N81.11 Cystocele, midline
644.03 Threatened preterm labor, antepartum (without delivery)
O47.00 False labor before 37 weeks of completed gestation, unspecified trimester
O47.02 False labor before 37 completed weeks of gestation, second trimester
O47.03
 False labor before 37 completed weeks of gestation, third trimester
O47.1
 False labor at or after 37 completed weeks of gestation
O47.9
 False labor, unspecified

 ** An additional code from category Z3A is needed to specify the weeks of gestation of the pregnancy.
648.33 Drug dependence, antepartum
O99.320 Drug use complicating pregnancy, unspecified trimester
O99.321 Drug use complicating pregnancy, first trimester
O99.322
 Drug use complicating pregnancy, second trimester
O99.323
 Drug use complicating pregnancy, third trimester

 **The codes from this subcategory require an additional code from F11-F16 and F18-F19 to identify manifestations of the drug use.

 **An additional code from category Z3A is needed to specify the weeks of gestation of the pregnancy.
626.2 Excessive menstruation
N92.0 Excessive and frequent menstruation with regular cycle
N92.1 Excessive and frequent menstruation with irregular cycle
N92.2
 Excessive menstruation at puberty
N92.4
 Excessive bleeding in the premenopausal period
627.3 Postmenopausal atrophic vaginitis
N95.2 Postmenopausal atrophicvaginitis
632 Missed abortion
O02.1 Missed abortion

** Use additional code from category 008 to identify any associated complication.

** An additional code from category Z3A is needed to specify the weeks of gestation of the pregnancy.
616.10 Vaginitis and vulvovaginitis, unspecified
N76.0 Acute vaginitis

** Use additional code (895-897), to identify infectious agent.

 There are other codes from this:
N76.1
 Subacute and chronic vaginitis
N76.2
 Acute vulvitis
N76.3
 Subacute and chronic vulvitis
N76.89
 Other specified inflammation of vagina and vulva
618.00 Unspecified prolapse of vaginal walls
N81.9 Female genital prolapse, unspecified
N81 .0
 Urethrocele
N81.10
 Cystocele, unspecified
N81.11
 Cystocele, midline
N81.12
 Cystocele, lateral
N81.2
 1ncomplete uterovaginal prolapse
N81.3
 Complete uterovaginal prolapsed
N81.4
 Uterovaginal prolapsed. unspecified
N81 .5
 Vaginal enterocele
N81 .6
 Rectocele
N81.81
 Perineocele
N81.82
 Incompetence or weakening of pubocervical tissue
N81.83
 Incompetence or weakening of rectovaginal tissue
N81.84
 Pelvic muscle wasting
N81.85
 Cervical stump prolapsed
N81.89
 Other female genital prolapsed
646.83 Other specified complications of pregnancy, antepartum
O26.891 Other specified pregnancy related conditions, first trimester
O26.892
 Other specified pregnancy related conditions, second trimester
O26.893
 Other specified pregnancy related conditions, third trimester
O26.899
 Other specified pregnancy related conditions, unspecified trimester

 * There are other code selections available for codes previously coded to 646.83:
O26.10
 Low weight gain in pregnancy, unspecified trimester
O26.11
 Low weight gain in pregnancy, first trimester
O26.12
 Low weight gain in pregnancy, second trimester
O26.13
 Low weight gain in pregnancy, third trimester
O26.40
 Herpes gestationis, unspecified trimester
O26.41
 Herpes gestation is, first trimester
O26.42
 Herpes gestationis, second trimester
O26.43
 Herpes gestationis, third trimester
O26.811
 Pregnancy related exhaustion and fatigue, first trimester
O26.812
 Pregnancy related exhaustion and fatigue. second trimester
O26.813
 Pregnancy related exhaustion and fatigue, third trimester
O26.819
 Pregnancy related exhaustion and fatigue, unspecified trimester

 ** An additional code from category Z3A is needed to specify the weeks of gestation of the pregnancy.
620.2 Ovarian cyst NOS/NEC
N83.20 Unspecified ovarian cysts
N83.29 Other ovarian cysts
N83.1
 Corpus luteum cyst
N83.0
 Follicular cyst of ovary
D27.9
 Benign neoplasm of unspecified ovary
Q50.1
 Developmental ovarian cyst
O34.80
 Maternal care for other abnormalities of pelvic organs,
O34.81
 Maternal care for other abnormalities of pelvic organs, first trimester
O34.82
 Maternal care for other abnormalities of pelvic organs,  second trimester
O34.83
 Maternal care for other abnormalities of pelvic organs, third trimester
O65.5
 Obstructed labor due to abnormality of maternal pelvic organs

 ** An additional code from category Z3A is needed to specify the weeks of gestation of the pregnancy.
623.9 Noninflammarory disorders of vagina, NOS
N89.8 Other specified noninflammatory disorders of vagina
N89.0 Mild vaginal dysplasia
N89.1
 Moderate vaginal dysplasia
N89.3
 Dysplasia of vagina, unspecified
N89.4
 Leukoplakia of vagina
N89.5
 Stricture and atresia of vagina
N89.6
 Tight hymenal ring
N89.7
 Hematocolpos
N89.9
 Noninflammatory disorder of vagina, unspecified
618.1 Uterine Prolapse w/o mention of vaginal wall prolapse
N81.2 1ncomplete uterovaginal prolapse
N81.3 Complete uterovaginal prolapse
N81.4
 Uterovaginal prolapse, unspecified
788.31 Urge intcontinence
N39.41 Urge incontinence

** Code also any associated overactive bladder (N32.81)
788.33 Mixed incontinence
N39.46 Mixed incontinence

** Code also any associated overactive bladder symptoms (N32.81)
789.03 Abdominal pain RLQ
R10.31 Right lower quadrant pain
625.6 Female stress incontinence
N39.3 Stress incontinence (female) (male)

** Code also any associated overactive bladder symptoms (N32.81)
V22.1 Supervision other normal pregnancy
Z34.80 Encounter for supervision of other normal pregnancy, unspecified trimester
Z34.81 Encounter for supervision of other normal pregnancy, first trimester
Z34.82
 Encounter for supervision of other normal pregnancy, second trimester
Z34.83
 Encounter for supervision of other normal pregnancy, third trimester
611.72 Lump or mass in breast
N63 Unspecified lump in breast
599.0 Urinary traer infection, NOS
N39.0 Urinary tract infection, sire not specified

** Use additional code (895-897), to identify infectious agent
N30.00
 Acute cystitis without hematuria
N30.01
 Acute cystitis with hematuria
N30.10
 Interstitial cystitis (chronic) without hematuria
N30.11
 Interstitial cystitis (chronic) with hematuria
N30.20
 Other chronic cystitis without hematuria
N30.21
 Other chronic cystitis with hematuria
N30.30
 Trigonitis without hematuria
N30.31
 Trigonitis with hematuria
N30.40
 Irradiation cystitis without hematuria
N30.41
 Irradiation cystitis with hematuria
N30.80
 Other cystitis without hematuria
N30.81
 Other cystitis with hematuria
N30.90
 Cystitis, unspecified without hematuria
N30.91
 Cystitis, unspecified with hematuria
N15.9
 Renal tubule-interstitial disease, unspecified
N34.1
 Nonspecific urethritis
N34.2
 Other urethritis
795.01 Papanicolaou smear of cervix with atypical squamous cells of undetermined significance ASC-US
R87.610 Atypical squamous cells of undetermined significance on cytologic smear of cervix (ASC-US)
R87.611 Atypical squamous cells cannot exclude high grade squamous intraepitheliallesion on cytologic smear of cervix (ASC-H)
R87.612
 Low grade squamous intraepitheliallesion on cytologic smear of cervix (LGSIL)
R87.613
 High grade squamous intraepitheliallesion on cytologic smear of cervix (HGSIL)
R87.614
 Cytologic evidence of malignancy on smear of cervix
R87.615
 Unsatisfactory cytologic smear of cervix
R87.616
 Satisfactory cervical smear but lacking transformation zone
R87.618
 Other abnormal cytological findings on specimens from cervix uteri
R87.619
 Unspecified abnormal cytological findings in specimens from cervix uteri
627.9 Menopausal disorder, NOS
N95.9 Unpsecified menopausal and perimenopausal disorder
N95.0 Postmenopausal bleeding
N95.1
 Menopausal and female climacteric states
N95.2
 Postmenopausal atrophic vaginitis
N95.8
 Other specified menopausal and perimenopausal disorders
642.43 Mild or unspecified pre-exlampsia, NOS
O14.00 Mild to moderate pre-eclampsia, unspecified trimester
O14.02 Mild to moderate pre-eclampsia, second trimester
O14.03
 Mild to moderate pre· eclampsia, third trimester
O14.90
 Unspecified pre-eclampsia, unspecified trimester
O14.92
 Unspecified pre-eclampsia, second trimester
O14.93
 Unspecified pre-eclampsia, third trimester

 ** An additional code from category Z3A is needed to specify the weeks of gestation of the pregnancy.
788.34 Incontinence without sensory awareness
N39.42 Incontinence without sensory awareness

** Code also any associated overactive bladder (N32.81)
V25.2 Desire for sterilization
Z30.2 Encounter for sterilization
626.4 Irregular menstrual cycle
N92.5 Other specified irregular me~struation
N92.6 1rregular menstruation, unspecified
N92.0
 Excessive and frequent menstruation with regular cycle
N92.1
 Excessive and frequent menstruation with irregular cycle
N92.2
 Excessive menstruation at puberty
N92.4
 Excessive bleeding in the premenopausal period
651.03 Twin pregnancy antepartum
O30.001 Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs. first trimester
O30.002 Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, second trimester
O30.003
 Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, third trimester
O30.009
 Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, unspecified trimester
O30.011
 Twin pregnancy, monochorionic/ monoamniotic, first trimester
O30.012
 Twin pregnancy, monochorionic/ monoamniotic, second trimester
O30.013
 Twin pregnancy, monochorionic/ monoamniotic, third trimester
O30.019
 Twin pregnancy, monochorionic/ monoamniotic, unspecified trimester
O30.031
 Twin pregnancy, monochorionic/ diamniotic, first trimester
O30.032
 Twin pregnancy, monochorionic/ diamniotic, second trimester
O30.033
 Twin pregnancy, monochorionic/ diamniotic, third trimester
O30.039
 Twin pregnancy, monochorionic/ diamniotic unspecified trimester
O30.041
 Twin pregnancy, dichorionic/ diamniotic, first trimester
O30.042
 Twin pregnancy, dichorionic/ diamniotic, second trimester
O30.043
 Twin pregnancy, dichorionic/ diamniotic, third trimester
O30.049
 Twin pregnancy, dichorionic/ diamniotic, unspecified 
O30.091
 Twin pregnancy. unable to determine number of placenta and number of amniotic sacs. first trimester
O30.092
 Twin pregnancy, unable to determine number of placenta and number of amniotic sacs, second trimester
O30.093
 Twin pregnancy, unable to determine number of placenta and number of amniotic sacs, third trimester
O30.099
 Twin pregnancy, unable to determine number of placenta and number of amniotic sacs, unspecified trimester

 ** An additional code from category Z3A is needed to specify the weeks of gestation of the pregnancy.
795.03 Papanicolaou smear of cervix with LGSIL
R87.612 Low grade squamous intraepitheliallesion on cytologic smear of cervix (LGSIL)
623.5 Leukorrhea, not specified as infective
N89.8 Other specified noninflamatory disorders of vagina 
V25.11 Insertion of IUD
Z30.430 Encounter for insertion of intrauterine contraceptive device
658.23 Delayed delivery after spontaneous or unspecified rupture of membranes, antepartum condition or complication
O42.111 Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, first trimester
O42.112 Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, second trimester
O42.113
 Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture. third trimester
O42.119
 Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, unspecified trimester

 ** An additional code from category Z3A is needed to specify the weeks of gestation of the pregnancy.
789.00 Abdominal pain site unspecified
R10.9 Unspecified abdominal pain
R10.0 Acute abdomen
R10.10
 Upper abdominal pain, unspecified
R10.11
 Right upper quadrant pain
R10.12
 Left upper quadrant pain
R10.13
 Epigastric pain
R10.2
 Pelvic and perineal pain
R10.30
 Lower abdominal pain, unspecified
R10.31
 Right lower quadrant pain
R10.32
 Left lower quadrant pain
R10.33
 Periumbilical pain
R10.84
 Generalized abdominal pain
V76.2 Screening malignant neoplasm cervix
Z12.4 Encounter for screening for malignant neoplasm of cervix
655.13 Maternal care for fetal chromosomal abnormality

*A 7th character extender must be assigned to code under category O35.
O35.1XX0 Maternal care for (suspected) chromosomal abnormality in fetus, not applicable or unspecified
O35.1XX1
 Maternal care for (suspected) chromosomal abnormality in fetus. fetus 1
O35.1XX2
 Maternal care for (suspected) chromosomal abnormality in fetus, fetus 2
O35.1XX3
 Maternal care for (suspected) chromosomal abnormality in fetus, fetus 3
O35.1XX4
 Maternal care for (suspected) chromosomal abnormality in fetus, fetus 4
O35.1XX5
 Maternal care for (suspected) chromosomal abnormality in fetus. fetus 5
O35.1XX9
 Maternal care for (suspected) chromosomal abnormality in fetus, other fetus

 One of the following 7th characters is to be assigned to each code under category 035. 7th character 0 is for single gestations and multiple gestations where the fetus is unspecified. 7th character I through 9 are for cases of multiple gestations to identify the fetus for which the code applies. The appropriate code from category 030, multiple gestation, must also be assigned when assigning a code from category 035 that has a 7th character of 1 through 9.

 7th Character extenders for subcategory 035-
0 Not Applicable or unspecified
1 Fetus 1
2 Fetus 2
3 Fetus 3
4 Fetus 4
5 Fetus 5
9 Other fetus

 ** An additional code from category Z3A is needed to specify the weeks of gestation of the pregnancy.
V28.3 Encounter for routine screening for malformation using ultrasonics (routine fetal ultrasound, NOS).
Z36 Encounter for antenatal screening of mother
788.20 Urinary retention, NOS
R33.9 Retention of urine. unspecified
R33.8 Other retention of urine
R33.0
 Drug induced retention of urine

 ** Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5).
F45.8
 Other somatoform disorders
789.04 Abdominal pain LLQ
R10.32 Left lower quadrant pain
789.07 Abdominal pain generalized
R10.84 Generalized abdominal pain
595.1 Interstitial cystitis chronic
N30.10 Interstitial cystitis (chronic) without hematuria
N30.11 Interstitial cystitis (chronic) with hematuria
595.9 Cystitis NOS
N30.90 Cystitis, unspecified without hem~turia
N30.91 Cystitis, unspecified with hem a tuna

*"Use additional code to identify infectious agent (895-897)
N30.00
 Acute cystitis without hematuria
N30.01
 Acute cystitis with hematuria
N30.10
 Interstitial cystitis (chronic) without hematuria
N30.11
 Interstitial cystitis (chronic) with hematuria
N30.20
 Other chronic cystitis without hematuria
N30.21
 Other chronic cystitis with hematuria
N30.30
 Trigonitis without hematuria
N30.31
 Trigonitis with hematuria
N30.40
 Irradiation cystitis without hematuria
N30.41
 Irradiation cystitis with hematuria
N30.80
 Other cystitis without hematuria
N30.81
 Other cystitis with hematuria
616.2 Bartholin's gland cyst
N75.0 Cyst of Bartholin's gland
616.4 Abcess of vulva NEC
N76.4 Abscess of vulva
V25.09 Contraceptive management NEC
Z30.09 Encounter for other general counseling and advice on contraception
Z30.8 Encounter for other contraceptive management
659.73 Abnormality in fetal heart rate or rhythm, antepartum
O76
 Abnormality in fetal heart rate and rhythm complicating Codes labor and delivery

** An additional code from category Z3A is needed to specify the weeks of gestation of the pregnancy.
Many codes from chapter 15 (000-099A) require the use of an additional code from category Z3A. Weeks of gestation, to identify the specific week of the pregnancy. These codes are for use, only on the maternal record, to indicate the weeks of gestation of the pregnancy.

Code first complications of pregnancy, childbirth and the puerperium (000-09A).
Z3A.00 Weeks of gestation of pregnancy not specified
Z3A.01
 Less than 8 weeks gestation of pregnancy
Z3A.08
 8 weeks gestation of pregnancy
Z3A.09
 9 weeks gestation of pregnancy
Z3A.10
 10 weeks gestation of pregnancy
Z3A.11
 11 weeks gestation of pregnancy
Z3A.12
 12 weeks gestation of pregnancy
Z3A.13
13 weeks gestation of pregnancy
Z3A.14
 14 weeks gestation of pregnancy
Z3A.15
 15 weeks gestation of pregnancy
Z3A.16
 16 weeks gestation of pregnancy
Z3A.17
 17 weeks gestation of pregnancy
Z3A.18
 18 weeks gestation of pregnancy
Z3A.19
 19 weeks gestation of pregnancy
Z3A.20
 20 weeks gestation of pregnancy
Z3A.21
 21 weeks gestation of pregnancy
Z3A.22
 22 weeks gestation of pregnancy
Z3A.23
 23 weeks gestation of pregnancy
Z3A.24
 24 weeks gestation of pregnancy
Z3A.25
 25 weeks gestation of pregnancy
Z3A.26
 26 weeks gestation of pregnancy
Z3A.27
 27 weeks gestation of pregnancy
Z3A.28
 28 weeks gestation of pregnancy
Z3A.29
 29 weeks gestation of pregnancy
Z3A.30
 30 weeks gestation of pregnancy
Z3A.31
 31 weeks gestation of pregnancy
Z3A.32
 32 weeks gestation of pregnancy
Z3A.33
 33 weeks gestation of pregnancy
Z3A.34
 34 weeks gestation of pregnancy
Z3A.35
 35 weeks gestation of pregnancy
Z3A.36
 36 weeks gestation of pregnancy
Z3A.37
 37 weeks gestation of pregnancy
Z3A.38
 38 weeks gestation of pregnancy
Z3A.39
 39 weeks gestation of pregnancy
Z3A.40
 40 weeks gestation of pregnancy
Z3A.41
 41 weeks gestation of pregnancy
Z3A.42
 42 weeks gestation of pregnancy
Z3A.49
 Greater than 42 weeks gestation of pregnancy
788.43 Nocturia
R35.1 Nocturia
112.1 Candidial vaginitis
B37.3 Candidiasis of vulva and vagina