ICD-10 Coding for History of Preterm Delivery(O09.211, Z87.71)
Complete ICD-10-CM coding and documentation guide for History of Preterm Delivery. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of Preterm Delivery
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| O09.211 | Supervision of pregnancy with history of pre-term labor, first trimester | Use for patients in the first trimester with a history of preterm delivery. |
|
| Z87.71 | Personal history of preterm labor | Use to indicate a past history of preterm labor. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for history of preterm delivery
Essential facts and insights about History of Preterm Delivery
Primary ICD-10-CM Codes for history of preterm delivery
Decision Criteria
clinical Criteria
- History of preterm delivery in a previous pregnancy.
coding Criteria
- Current pregnancy in the first trimester.
Applicable To
- Supervision of pregnancy with history of pre-term labor in the first trimester
Excludes
- Current preterm labor (O60.1-)
Clinical Validation Requirements
- Documented history of preterm delivery
- Current pregnancy in the first trimester
Code-Specific Risks
- Incorrect trimester specification
Coding Notes
- Ensure trimester is correctly documented to select the appropriate O09.21- code.
Z87.71 - Personal history of preterm labor
Use to indicate a past history of preterm labor.
Applicable To
- History of preterm labor
Excludes
- Current preterm labor (O60.1-)
Clinical Validation Requirements
- Documented history of preterm labor in medical records
Coding Notes
Always pair with an O09.21- code during a current pregnancy.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting History of Preterm Delivery to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code O09.211.
Impact
Clinical: Inaccurate risk assessment and management., Regulatory: Non-compliance with ICD-10 coding guidelines., Financial: Potential for incorrect billing and reimbursement.
Mitigation Strategy
Always document the current trimester in patient records.
Impact
Reimbursement: May lead to incorrect DRG assignment and lower reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate representation of patient risk status.
Mitigation Strategy
Always pair Z87.71 with O09.21- for active prenatal care.
Impact
Missing trimester information can lead to incorrect coding.
Mitigation Strategy
Ensure trimester is documented in all prenatal visits.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for History of Preterm Delivery, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Preterm Delivery
Use these documentation templates to ensure complete and accurate documentation for History of Preterm Delivery. These templates include all required elements for proper coding and billing.
Prenatal visit for patient with history of preterm delivery
Specialty: ObstetricsRequired Elements
- Gestational age
- History of preterm delivery details
- Current management plan
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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