ICD Code O46.90

ICD code O46.90 is used to classify a condition where there is bleeding from the uterus during pregnancy, but the specific cause of the bleeding is not identified. This code does not specify the trimester in which the bleeding occurs, indicating that it could happen at any point before childbirth. This code is crucial for healthcare providers to document and manage cases of antepartum hemorrhage when the details are not fully known, ensuring appropriate care and monitoring.

1. Presence of Vaginal Bleeding: The patient exhibits vaginal bleeding during pregnancy, which is not associated with labor or delivery.

2. Exclusion of Other Causes: Other potential causes of bleeding, such as placental abruption, placenta previa, or gestational trophoblastic disease, have been ruled out through clinical evaluation and diagnostic testing.

3. Lack of Specific Diagnosis: The bleeding cannot be attributed to a specific condition or diagnosis, making it necessary to use an unspecified code.

4. Trimester Unspecified: The trimester during which the bleeding occurs is not specified in the medical records or is unknown at the time of diagnosis.

5. Antepartum Period: The bleeding occurs during the antepartum period, which is the time before the onset of labor.

6. Clinical Evaluation: The patient has undergone a thorough clinical evaluation, including history taking and physical examination, to assess the severity and potential impact of the hemorrhage on maternal and fetal health.

7. Documentation: The medical records clearly document the occurrence of antepartum hemorrhage without specifying the underlying cause or trimester, necessitating the use of an unspecified code.

For the ICD code O46.90, which pertains to antepartum hemorrhage, unspecified, unspecified trimester, the relevant CPT codes that may be applicable for treatment or management include:

1. 99201-99205 - Office or other outpatient visit for the evaluation and management of a new patient.

2. 99211-99215 - Office or other outpatient visit for the evaluation and management of an established patient.

3. 99241-99245 - Office consultation for a new or established patient.

4. 59510 - Routine obstetric care including antepartum care, cesarean delivery, and postpartum care.

5. 59400 - Routine obstetric care including antepartum care, vaginal delivery, and postpartum care.

6. 76801 - Ultrasound, pregnant uterus, real-time with image documentation, fetal and maternal evaluation, first trimester.

7. 76805 - Ultrasound, pregnant uterus, real-time with image documentation, fetal and maternal evaluation, after first trimester.

8. 76815 - Ultrasound, pregnant uterus, real-time with image documentation, limited (e.g., fetal heartbeat, placental location, fetal position and/or qualitative amniotic fluid volume), one or more fetuses.

These CPT codes are examples of procedures and services that might be used in the evaluation, management, and treatment of conditions associated with the ICD code O46.90. It is important for healthcare providers to select the most appropriate CPT code based on the specific services rendered and the clinical scenario.

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