Pathology/Lab Coding Alert

Question: The pathologist examined a fetus from a spontaneous abortion; the patient was carrying twins, and the second twin remains. The fetus did not show any abnormalities. I’ve been told that O31.10 is the correct diagnosis. Is that correct, and what is the procedure code?

Washington Subscriber

Answer: No, O31.10 (Continuing pregnancy after spontaneous abortion of one fetus or more, unspecified trimester) would not be the correct diagnosis code. First of all, that is a truncated code, so you would need to assign a complete code to the 7th character, such as O31.10X0 (Continuing pregnancy after spontaneous abortion of one fetus or more, unspecified trimester, not applicable or unspecified). But the bigger problem is that this diagnosis code addresses the maternal diagnosis, and you need to describe the diagnosis of the aborted fetus.

Better: The correct code to describe the fetal diagnosis is O03.9 (Complete or unspecified spontaneous abortion without complication).

Regarding the procedure code, you should assign 88305 (Level IV - Surgical pathology, gross and microscopic examination Abortion - spontaneous/missed…) to describe the pathologist’s exam of the fetus.