Ob-Gyn Coding Alert

Question: My ob-gyn did an ultrasound for an indication of "size less than dates." Should I report 649.63 or 656.53 as the diagnosis?

Connecticut Subscriber

Answer: You need more information from the provider. Code 649.63 (Uterine size date discrepancy, antepartum condition or complication) means the patient's UTERINE size is less than dates. Code 656.53 (Poor fetal growth affecting management of mother, antepartum condition or complication) means the FETUS is smaller than dates. Therefore, the ob-gyn needs to tell you if he did the ultrasound to evaluate the uterus or fetus.

ICD-10: In 2013, your options for 649.63 expand into three options, based on trimester: O26.841 (Uterine size-date discrepancy, first trimester), O26.842 (... second trimester), or O26.843 (... third trimester).

As for your ICD-10 options for 656.53, you have more than three options, and again, they are based on trimester:

• O36.5110 -- Maternal care for known or suspected placentalinsufficiency, first trimester, not applicable or unspecified
• O35.5120 -- ... second trimester ...
• O36.5130 -- ... third trimester ...
• O36.5910 -- Maternal care for other known or suspected fetal growth, first trimester, not applicable or unspecified
• O36.5920 -- ... second trimester ...
• O36.5930 -- ... third trimester ...