Medical terminology of a fetus not carried to full term.
Today I am going to talk about what seems to be a very politically charged topic at the moment, but I am not actually going there. I want to review the term “abortion,” in medical terminology, and discuss procedures relating to a fetus not carried to full term.
People generally do not read the textbook. Although ovulation is usually asserted to occur around 14 days prior to onset of menses, with a fertility period of approximately six days preceding and including the day of ovulation, in reality, the time during which a woman can conceive is rather variable, and often unpredictable. Adolescent and perimenopausal individuals, and women with irregular menses, have even less reliable timing.
Fertilization of the egg by the sperm occurs in the fallopian tube during that fertile period, and under normal circumstances, the fertilized egg travels down until it reaches the uterus, and the 70 to 100 cell blastocyst then implants against the uterine wall. There are differing opinions as to whether conception is considered the moment of fertilization or implantation. However, unless implantation occurs (in a normal uterine location), there is no chance of a pregnancy that will result in delivery of a baby. The fertilized yet-not-implanted egg gets expelled during menstruation.
The word “embryo” refers to the period from time of implantation to the end of the eighth week after conception. From the beginning of the ninth week on, it is called a “fetus.” At the moment of delivery, the term is “neonate,” newborn infant, or baby. Fetuses are not viable prior to 22 weeks of gestation, and likelihood of survival increases to between 60 and 70 percent at 24 weeks gestation. About 40 percent of premature infants at this age will suffer long-term health complications.
An ectopic pregnancy is when a fertilized egg grows outside of the main cavity of the uterus. More than 90 percent of these occur in a fallopian tube at high risk for rupture. Other locations include ovarian, in an abnormal area in the uterus (like cornual, cervical, or in a cesarean scar), or abdominal. Ectopic pregnancies can be further complicated by occurring in concert with an intrauterine pregnancy, often because they are more common in cases of infertility treatment. “Uncomplicated” ectopic pregnancy ICD-10-CM codes are found in O00.-, and codes for ectopic and molar pregnancies with complications are housed in O08.-.
Fetal survival of an ectopic pregnancy is exceedingly rare, and there is a grave threat to the mother’s life if it is not terminated in a timely fashion. The only treatment for an ectopic pregnancy is ending the pregnancy, and it often requires surgical intervention, which results in excision/resection of the affected body part.
The medical definition of abortion is “the termination of a pregnancy after, accompanied by, resulting in, or closely followed by the death of the embryo or fetus.” Secondary definitions are “spontaneous expulsion of a human fetus during the first 12 weeks of gestation” and “induced expulsion of a human fetus.”
In other words, a miscarriage, in medical terms, is called a spontaneous abortion. The most common causes of miscarriage are genetic or chromosomal abnormalities, placental issues, medical or anatomical conditions involving the mother, and infection. Spontaneous abortions most commonly occur so early in the pregnancy (weeks 0-6) that the patient may not even be aware they are pregnant, and may think it is just a late period. An estimated 10-15 percent of known pregnancies end in miscarriage.
If the embryo or fetus dies and the body naturally expels all the products of conception, it is termed “complete abortion.” If some of the products pass, but some parts of the fetus, placenta, or membranes are retained, it is called an “incomplete abortion.” An “inevitable abortion” is the scenario when the cervix has dilated in preparation for expulsion, but has not yet done so. For some coding reason unfathomable to me as a clinician, inevitable abortion indexes to O03.4, Incomplete spontaneous abortion without complication.
A “missed abortion” (O02.1) is when a fetus has died (not proximately, usually days to weeks ago), but the body does not proceed to expel the nonviable intrauterine pregnancy. A “septic abortion” is a result of intrauterine infection following an abortion. Finally, a “threatened abortion” (O20.0) is vaginal bleeding in pregnancy before 20 weeks with a closed cervix (i.e., not an inevitable abortion). A total of 25 percent of pregnancies have some bleeding in early pregnancy, and approximately half of these progress to abortion.
There are other complications of pregnancy that can result in the need for removal of nonviable products of conception. These include a blighted ovum (O02.0), in which an early embryo never develops or arrests, and a hydatidiform mole (AKA molar pregnancy, O01.-), when a noncancerous tumor forms instead of a healthy placenta. Complete and incomplete spontaneous abortions and their complications, such as pelvic infection, hemorrhage, sepsis, and shock, are coded in O03.-.
These spontaneous pregnancy losses are distinct from elective termination of pregnancy. In ICD-10-CM, there is a distinction between an encounter for elective termination of pregnancy without complications (Z33.2) and conditions/complications following induced (O04.-) or failed attempted termination (O07.-) of pregnancy.
Inducing abortion can either be accomplished by procedural or medical means. For outpatient procedures, Current Procedural Terminology (CPT) codes are utilized. The American College of Obstetrics and Gynecology (ACOG) recommends that abortions after 20 weeks be reported using a delivery code. However, they stipulate that some state legislatures legally define the distinction between a miscarriage and a stillbirth by the number of weeks or by weight, and this may guide the choice of CPT code.
If a patient is admitted in the hospital, then ICD-10-PCS codes are used. The body part for the obstetrics section is always some version of products of conception (POC, retained products, or ectopic).
I hope this sheds light on the definitions, ICD-10-CM diagnoses, and procedure coding of miscarriage and abortion. It’s the best I can do.
Resources:
Today I want to focus on the critical role of ICD-10 coding in the field of mental health and behavioral disorders. Accurate coding in this
The new ICD-10-PCS codes for the 2025 fiscal year (FY) were posted on the Centers for Medicare & Medicaid Services website on June 6. The
Please log in to your account to comment on this article.
During this webcast Dr. Ronald Hirsch delves into the inpatient admission order process including when to get it, when it becomes effective, its impact on billing and payment, who can write it, how to cancel it, the effects on the beneficiary, and more. You’ll leave with a clear understanding of inpatient orders and guidelines for handling improper orders that you can implement immediately.
Michelle Wieczorek explores challenges, strategies, and best practices to AI implementation and ongoing monitoring in the middle revenue cycle through real-world use cases. She addresses critical issues such as the validation of AI algorithms, the importance of human validation in machine learning, and the delineation of responsibilities between buyers and vendors.
Frank Cohen shows you how to leverage the Comprehensive Error Rate Testing Program (CERT) to create your own internal coding and billing risk assessment plan, including granular identification of risk areas and prioritizing audit tasks and functions resulting in decreased claim submission errors, reduced risk of audit-related damages, and a smoother, more efficient reimbursement process from Medicare.
Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.
Optimize your inpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. Participants will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Join expert Angela Comfort, MBA, RHIA, CDIP, CCS, CCS-P., as she helps you navigate advanced inpatient CDI technologies, regulatory changes, and system interoperability. Angela will provide actionable strategies for integrating AI and predictive analytics into CDI practices, ensuring seamless system interoperability, and maintaining compliance with evolving regulations. Attendees will learn to select and implement advanced EHR systems and CDI software, leverage data analytics to enhance documentation accuracy, and stay audit-ready with the latest compliance updates. Real-world case studies and practical tools will empower you to drive continuous improvement in CDI, improve patient outcomes, and enhance organizational efficiency. Don’t miss this opportunity to advance your CDI practices and stay ahead in this dynamic field.
Join expert Angela Comfort, MBA, RHIA, CDIP, CCS, CCS-P, for an insightful webcast on improving inpatient clinical documentation integrity (CDI). Inaccurate documentation can lead to misdiagnosis, improper treatment, and compromised patient safety. High workloads, lack of standardized practices, and outdated EHR systems contribute to these issues, affecting care quality and financial outcomes. Angela will offer practical strategies and tools to enhance accuracy, consistency, and timeliness in documentation. Attendees will learn to use standardized templates, checklists, and advanced EHR systems, while staying compliant with regulations. Improve patient care, ensure accurate billing, and reduce audit risks with actionable insights from this essential webcast.
Join industry expert, Kathy Pride, RHIT, CPC, CPMA, CCS-P, for an in-depth exploration of Evaluation and Management (E/M) coding, tailored for healthcare professionals navigating recent guideline changes. Dive into advanced topics beyond mere code selection, including shared visits, criteria for selecting E/M levels, and documentation best practices. Gain clarity on complex guideline terminology and ensure compliance with regulatory standards. This comprehensive session is essential for coders, auditors, educators, and practitioners seeking to enhance their proficiency in E/M coding and maximize revenue capture.
Copyright © 2024 ICD10monitor. Powered by MedLearn Media.
Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!
