Documentation of trimester is required. To determine trimester, calculate from the first day of last menstrual period and is documented in weeks as follows:
First trimester: Less than 14 weeks, 0 days
Second trimester: 14 weeks, 0 days – 27 weeks, 6 days
Third trimester: 28 weeks – delivery
Other OB concepts in ICD-10:
- The time frame for differentiating between early and late vomiting in pregnancy has been changed 22 to 20 weeks
- The time frame for a missed abortion (vs fetal death) has changed from 22 to 20 weeks
- In ICD-10-CM, an elective abortion is now described as an elective termination of pregnant
- There are four spontaneous abortion definitions in ICD-10; use the appropriate definition in your documentation
- Missed abortion no Bleeding, os closed
- Threatened abortion Bleeding, os closed
- Incomplete abortion Bleeding, os open, products of conception (POC) are extruding
- Complete abortion Possible bleeding or spotting, os closed, all POC expelled
- Documentation of conditions/complications of pregnancy need to distinguish between preexisting conditions or pregnancy related conditions
- Include the following when documenting complications of pregnancy
- Condition detail – was the condition preexisting, or present before pregnancy
- Trimester – when did the pregnancy related condition develop?
- Causal relationship – establish the relationship between pregnancy and the complication (e.g. preeclampsia)