Ob-Gyn Coding Alert

Don’t overlook these Includes notes.

Preterm labor is labor that begins more than three weeks before the patient expects to deliver her baby but after the 20th week of pregnancy. Contractions may cause the cervix to open earlier than normal. Notice that there is no ICD-9-CM code for preterm labor with delivery. You would code that situation with 644.2x.

Currently, you should report preterm labor with:

• 644.00, Threatened premature labor unspecified as to episode of care
  
• 644.03, Threatened premature labor antepartum
  

ICD-10-CM Codes: When your diagnosis system changes after October 1, 2014, you have three new options:

• O60.00, Preterm labor without delivery, unspecified trimester
• O60.02, Preterm labor without delivery, second trimester
• O60.03, Preterm labor without delivery, third trimester

Change: These three choices specify second trimester (O60.02) or third trimester (O60.03). If your provider does not specify which trimester, you would use O60.00. When the premature labor results in premature delivery, you should select a different set of codes.

Documentation: In order to report these preterm labor codes, the provider must document that the preterm labor occurred without delivery and the pregnancy’s trimester.

Here is how you’ll find these codes in the Alphabetic Index:

Pregnancy (childbirth) (labor) (puerperium) —see also Delivery and Puerperal

- complicated by (care of) (management affected by)
- - preterm labor
- - - without delivery O60.00
- - - - second trimester O60.02
- - - - third trimester O60.03
- - - second trimester
- - - - with preterm delivery
- - - - without delivery O60.02
- - - third trimester
- - - - without delivery O60.03

Coders tips: You will see an Includes notes under the preterm labor category (O60) that says that these codes include onset (spontaneous) of labor before 37 completed weeks of gestation.

You will also see an Excludes1 note that forbids you from reporting these codes with false labor (O47.0-) or threatened labor NOS (O47.0-).