Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up Plan (2022)

eCQMs / NQF #: CMS69v10 / XXXX
Measure: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if most recent BMI was outside of normal parameters.
Numerator: Patients with a documented BMI during the encounter or during the previous twelve months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter.
Denominator: All patients aged 18 and older on the date of the encounter with at least one eligible encounter during the measurement period.
Denominator Exclusion: Patients who are pregnant.

Patients receiving palliative or hospice care.

Denominator Exceptions: Patients with a documented medical reason for not documenting BMI or for not documenting a follow-up plan for a BMI outside normal parameters (e.g., elderly patients (65 or older) for whom weight reduction/weight gain would complicate other underlying health conditions such as illness or physical disability, mental illness, dementia, confusion, or nutritional deficiency such as vitamin/mineral deficiency; patients in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status).

Patients who refuse measurement of height and/or weight.

Domain: Community/Population Health

 

In ChartMaker Clinical:

In order to qualify for this measure, the provider must have seen the patient, age 18 and older, at least one time during the reporting period and have the appropriate information documented in the chart:

Required Data Elements for the Denominator:

This is captured by adding a procedure with a valid CPT, HCPCS, or SNOMED code using the Procedure widget in a note.

CPT/HCPCS:  
Code Description
90791 Psychiatric diagnostic evaluation
90792 Psychiatric diagnostic evaluation with medical services
90832 Psychotherapy, 30 minutes with patient
90834 Psychotherapy, 45 minutes with patient
90837 Psychotherapy, 60 minutes with patient
96156 Health behavior assessment, or re-assessment (ie, health-focused clinical interview, behavioral observations, clinical decision making)
96158 Health behavior intervention, individual, face-to-face; initial 30 minutes
96159 Health behavior intervention, individual, face-to-face; each additional 15 minutes (List separately in addition to code for primary service)
97161 Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family.
97162 Physical therapy evaluation: moderate complexity, requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; An evolving clinical presentation with changing characteristics; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the patient and/or family.
97163 Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family.
97165 Occupational therapy evaluation, low complexity, requiring these components: An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem; An assessment(s) that identifies 1-3 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (eg, physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component. Typically, 30 minutes are spent face-to-face with the patient and/or family.
97166 Occupational therapy evaluation, moderate complexity, requiring these components: An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 3-5 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 45 minutes are spent face-to-face with the patient and/or family.
97167 Occupational therapy evaluation, high complexity, requiring these components: An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 5 or more performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 60 minutes are spent face-to-face with the patient and/or family.
97802 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes
97803 Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes
99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family.
99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.
99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.
99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.
99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.
99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.
99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.
99236 Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) requiring admission are of high severity. Typically, 55 minutes are spent at the bedside and on the patient’s hospital floor or unit.
99304 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of low severity. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit.
99305 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit.
99306 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient’s facility floor or unit.
99307 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Typically, 10 minutes are spent at the bedside and on the patient’s facility floor or unit.
99308 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 15 minutes are spent at the bedside and on the patient’s facility floor or unit.
99309 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient has developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit.
99310 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit.
99315 Nursing facility discharge day management; 30 minutes or less
99316 Nursing facility discharge day management; more than 30 minutes
99318 Evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components: A detailed interval history; A comprehensive examination; and Medical decision making that is of low to moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Typically, 30 minutes are spent at the bedside and on the patient’s facility floor or unit.
99324 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 20 minutes are spent with the patient and/or family or caregiver.
99325 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent with the patient and/or family or caregiver.
99326 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent with the patient and/or family or caregiver.
99327 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent with the patient and/or family or caregiver.
99328 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent with the patient and/or family or caregiver.
99334 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 15 minutes are spent with the patient and/or family or caregiver.
99335 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent with the patient and/or family or caregiver.
99336 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent with the patient and/or family or caregiver.
99337 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent with the patient and/or family or caregiver.
99339 Individual physician supervision of a patient (patient not present) in home, domiciliary or rest home (eg, assisted living facility) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes
99340 Individual physician supervision of a patient (patient not present) in home, domiciliary or rest home (eg, assisted living facility) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more
99385 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years
99386 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years
99387 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older
99395 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years
99396 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years
99397 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older
99401 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes
99402 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes
G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination
G0108 Diabetes outpatient self-management training services, individual, per 30 minutes
G0270 Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes
G0271 Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes
G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment
G0438 Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit
G0439 Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit
G0447 Face-to-face behavioral counseling for obesity, 15 minutes
G0473 Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes

 

SNOMED:  
Code Description
10197000 Psychiatric interview and evaluation (procedure)
108220007 Evaluation AND/OR management – new patient (procedure)
108221006 Evaluation AND/OR management – established patient (procedure)
108224003 Preventive patient evaluation (procedure)
108311000 Psychiatric procedure, interview AND/OR consultation (procedure)
13607009 Manual examination of breast (procedure)
14736009 History and physical examination with evaluation and management of patient (procedure)
165171009 Initial psychiatric evaluation (procedure)
18512000 Individual psychotherapy (regime/therapy)
185349003 Encounter for check up (procedure)
185463005 Visit out of hours (procedure)
185465003 Weekend visit (procedure)
225967005 Self-care patient education (procedure)
270427003 Patient-initiated encounter (procedure)
270430005 Provider-initiated encounter (procedure)
308335008 Patient encounter procedure (procedure)
35025007 Manual pelvic examination (procedure)
386372009 Nutrition management (regime/therapy)
390906007 Follow-up encounter (procedure)
406547006 Urgent follow-up (procedure)
410155007 Occupational therapy assessment (procedure)
410157004 Occupational therapy management (procedure)
410158009 Physical therapy assessment (procedure)
410160006 Physical therapy management (procedure)
410170008 Nutrition care assessment (procedure)
410172000 Nutrition care management (procedure)
46662001 Examination of breast (procedure)
55162003 Tooth extraction (procedure)
68381003 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth (procedure)
78318003 History and physical examination, annual for health maintenance (procedure)
83607001 Gynecologic examination (procedure)
8411005 Interactive individual medical psychotherapy (regime/therapy)
86013001 Periodic reevaluation and management of healthy individual (procedure)
90526000 Initial evaluation and management of healthy individual (procedure)

Denominator Exclusions & Exceptions:

If one of the following is documented, the patient will not be included in the denominator:

This is captured by adding a diagnosis with a valid ICD10 or SNOMED code using the Diagnosis widget in a note.

ICD-10:  
Code Description
O00.00 Abdominal pregnancy without intrauterine pregnancy
O00.01 Abdominal pregnancy with intrauterine pregnancy
O00.101 Right tubal pregnancy without intrauterine pregnancy
O00.102 Left tubal pregnancy without intrauterine pregnancy
O00.109 Unspecified tubal pregnancy without intrauterine pregnancy
O00.111 Right tubal pregnancy with intrauterine pregnancy
O00.112 Left tubal pregnancy with intrauterine pregnancy
O00.119 Unspecified tubal pregnancy with intrauterine pregnancy
O00.201 Right ovarian pregnancy without intrauterine pregnancy
O00.202 Left ovarian pregnancy without intrauterine pregnancy
O00.209 Unspecified ovarian pregnancy without intrauterine pregnancy
O00.211 Right ovarian pregnancy with intrauterine pregnancy
O00.212 Left ovarian pregnancy with intrauterine pregnancy
O00.219 Unspecified ovarian pregnancy with intrauterine pregnancy
O00.80 Other ectopic pregnancy without intrauterine pregnancy
O00.81 Other ectopic pregnancy with intrauterine pregnancy
O00.90 Unspecified ectopic pregnancy without intrauterine pregnancy
O00.91 Unspecified ectopic pregnancy with intrauterine pregnancy
O01.9 Hydatidiform mole, unspecified
O02.0 Blighted ovum and nonhydatidiform mole
O02.1 Missed abortion
O03.0 Genital tract and pelvic infection following incomplete spontaneous abortion
O03.1 Delayed or excessive hemorrhage following incomplete spontaneous abortion
O03.2 Embolism following incomplete spontaneous abortion
O03.30 Unspecified complication following incomplete spontaneous abortion
O03.31 Shock following incomplete spontaneous abortion
O03.32 Renal failure following incomplete spontaneous abortion
O03.33 Metabolic disorder following incomplete spontaneous abortion
O03.34 Damage to pelvic organs following incomplete spontaneous abortion
O03.37 Sepsis following incomplete spontaneous abortion
O03.39 Incomplete spontaneous abortion with other complications
O03.4 Incomplete spontaneous abortion without complication
O03.5 Genital tract and pelvic infection following complete or unspecified spontaneous abortion
O03.6 Delayed or excessive hemorrhage following complete or unspecified spontaneous abortion
O03.7 Embolism following complete or unspecified spontaneous abortion
O03.80 Unspecified complication following complete or unspecified spontaneous abortion
O03.81 Shock following complete or unspecified spontaneous abortion
O03.82 Renal failure following complete or unspecified spontaneous abortion
O03.83 Metabolic disorder following complete or unspecified spontaneous abortion
O03.84 Damage to pelvic organs following complete or unspecified spontaneous abortion
O03.85 Other venous complications following complete or unspecified spontaneous abortion
O03.86 Cardiac arrest following complete or unspecified spontaneous abortion
O03.87 Sepsis following complete or unspecified spontaneous abortion
O03.88 Urinary tract infection following complete or unspecified spontaneous abortion
O03.89 Complete or unspecified spontaneous abortion with other complications
O03.9 Complete or unspecified spontaneous abortion without complication
O04.5 Genital tract and pelvic infection following (induced) termination of pregnancy
O04.6 Delayed or excessive hemorrhage following (induced) termination of pregnancy
O04.7 Embolism following (induced) termination of pregnancy
O04.80 (Induced) termination of pregnancy with unspecified complications
O04.81 Shock following (induced) termination of pregnancy
O04.82 Renal failure following (induced) termination of pregnancy
O04.83 Metabolic disorder following (induced) termination of pregnancy
O04.84 Damage to pelvic organs following (induced) termination of pregnancy
O04.85 Other venous complications following (induced) termination of pregnancy
O04.86 Cardiac arrest following (induced) termination of pregnancy
O04.87 Sepsis following (induced) termination of pregnancy
O04.88 Urinary tract infection following (induced) termination of pregnancy
O04.89 (Induced) termination of pregnancy with other complications
O07.0 Genital tract and pelvic infection following failed attempted termination of pregnancy
O07.1 Delayed or excessive hemorrhage following failed attempted termination of pregnancy
O07.2 Embolism following failed attempted termination of pregnancy
O07.30 Failed attempted termination of pregnancy with unspecified complications
O07.31 Shock following failed attempted termination of pregnancy
O07.32 Renal failure following failed attempted termination of pregnancy
O07.33 Metabolic disorder following failed attempted termination of pregnancy
O07.34 Damage to pelvic organs following failed attempted termination of pregnancy
O07.35 Other venous complications following failed attempted termination of pregnancy
O07.36 Cardiac arrest following failed attempted termination of pregnancy
O07.37 Sepsis following failed attempted termination of pregnancy
O07.38 Urinary tract infection following failed attempted termination of pregnancy
O07.39 Failed attempted termination of pregnancy with other complications
O07.4 Failed attempted termination of pregnancy without complication
O08.0 Genital tract and pelvic infection following ectopic and molar pregnancy
O08.1 Delayed or excessive hemorrhage following ectopic and molar pregnancy
O08.2 Embolism following ectopic and molar pregnancy
O08.3 Shock following ectopic and molar pregnancy
O08.4 Renal failure following ectopic and molar pregnancy
O08.5 Metabolic disorders following an ectopic and molar pregnancy
O08.6 Damage to pelvic organs and tissues following an ectopic and molar pregnancy
O08.7 Other venous complications following an ectopic and molar pregnancy
O08.81 Cardiac arrest following an ectopic and molar pregnancy
O08.82 Sepsis following ectopic and molar pregnancy
O08.83 Urinary tract infection following an ectopic and molar pregnancy
O08.89 Other complications following an ectopic and molar pregnancy
O08.9 Unspecified complication following an ectopic and molar pregnancy
O09.00 Supervision of pregnancy with history of infertility, unspecified trimester
O09.10 Supervision of pregnancy with history of ectopic pregnancy, unspecified trimester
O09.11 Supervision of pregnancy with history of ectopic pregnancy, first trimester
O09.12 Supervision of pregnancy with history of ectopic pregnancy, second trimester
O09.13 Supervision of pregnancy with history of ectopic pregnancy, third trimester
O09.211 Supervision of pregnancy with history of pre-term labor, first trimester
O09.291 Supervision of pregnancy with other poor reproductive or obstetric history, first trimester
O09.30 Supervision of pregnancy with insufficient antenatal care, unspecified trimester
O09.40 Supervision of pregnancy with grand multiparity, unspecified trimester
O09.41 Supervision of pregnancy with grand multiparity, first trimester
O09.42 Supervision of pregnancy with grand multiparity, second trimester
O09.43 Supervision of pregnancy with grand multiparity, third trimester
O09.511 Supervision of elderly primigravida, first trimester
O09.512 Supervision of elderly primigravida, second trimester
O09.513 Supervision of elderly primigravida, third trimester
O09.519 Supervision of elderly primigravida, unspecified trimester
O09.521 Supervision of elderly multigravida, first trimester
O09.522 Supervision of elderly multigravida, second trimester
O09.523 Supervision of elderly multigravida, third trimester
O09.529 Supervision of elderly multigravida, unspecified trimester
O09.611 Supervision of young primigravida, first trimester
O09.621 Supervision of young multigravida, first trimester
O09.819 Supervision of pregnancy resulting from assisted reproductive technology, unspecified trimester
O09.821 Supervision of pregnancy with history of in utero procedure during previous pregnancy, first trimester
O09.822 Supervision of pregnancy with history of in utero procedure during previous pregnancy, second trimester
O09.823 Supervision of pregnancy with history of in utero procedure during previous pregnancy, third trimester
O09.829 Supervision of pregnancy with history of in utero procedure during previous pregnancy, unspecified trimester
O09.891 Supervision of other high risk pregnancies, first trimester
O09.892 Supervision of other high risk pregnancies, second trimester
O09.893 Supervision of other high risk pregnancies, third trimester
O09.899 Supervision of other high risk pregnancies, unspecified trimester
O09.90 Supervision of high risk pregnancy, unspecified, unspecified trimester
O09.91 Supervision of high risk pregnancy, unspecified, first trimester
O09.92 Supervision of high risk pregnancy, unspecified, second trimester
O09.93 Supervision of high risk pregnancy, unspecified, third trimester
O09.A0 Supervision of pregnancy with history of molar pregnancy, unspecified trimester
O09.A1 Supervision of pregnancy with history of molar pregnancy, first trimester
O09.A2 Supervision of pregnancy with history of molar pregnancy, second trimester
O09.A3 Supervision of pregnancy with history of molar pregnancy, third trimester
O10.011 Pre-existing essential hypertension complicating pregnancy, first trimester
O10.012 Pre-existing essential hypertension complicating pregnancy, second trimester
O10.013 Pre-existing essential hypertension complicating pregnancy, third trimester
O10.019 Pre-existing essential hypertension complicating pregnancy, unspecified trimester
O10.03 Pre-existing essential hypertension complicating the puerperium
O10.111 Pre-existing hypertensive heart disease complicating pregnancy, first trimester
O10.112 Pre-existing hypertensive heart disease complicating pregnancy, second trimester
O10.113 Pre-existing hypertensive heart disease complicating pregnancy, third trimester
O10.119 Pre-existing hypertensive heart disease complicating pregnancy, unspecified trimester
O10.12 Pre-existing hypertensive heart disease complicating childbirth
O10.13 Pre-existing hypertensive heart disease complicating the puerperium
O10.211 Pre-existing hypertensive chronic kidney disease complicating pregnancy, first trimester
O10.212 Pre-existing hypertensive chronic kidney disease complicating pregnancy, second trimester
O10.213 Pre-existing hypertensive chronic kidney disease complicating pregnancy, third trimester
O10.219 Pre-existing hypertensive chronic kidney disease complicating pregnancy, unspecified trimester
O10.22 Pre-existing hypertensive chronic kidney disease complicating childbirth
O10.23 Pre-existing hypertensive chronic kidney disease complicating the puerperium
O10.311 Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, first trimester
O10.312 Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, second trimester
O10.313 Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, third trimester
O10.319 Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, unspecified trimester
O10.32 Pre-existing hypertensive heart and chronic kidney disease complicating childbirth
O10.33 Pre-existing hypertensive heart and chronic kidney disease complicating the puerperium
O10.411 Pre-existing secondary hypertension complicating pregnancy, first trimester
O10.412 Pre-existing secondary hypertension complicating pregnancy, second trimester
O10.413 Pre-existing secondary hypertension complicating pregnancy, third trimester
O10.419 Pre-existing secondary hypertension complicating pregnancy, unspecified trimester
O10.42 Pre-existing secondary hypertension complicating childbirth
O10.43 Pre-existing secondary hypertension complicating the puerperium
O10.911 Unspecified pre-existing hypertension complicating pregnancy, first trimester
O10.912 Unspecified pre-existing hypertension complicating pregnancy, second trimester
O10.913 Unspecified pre-existing hypertension complicating pregnancy, third trimester
O10.919 Unspecified pre-existing hypertension complicating pregnancy, unspecified trimester
O10.92 Unspecified pre-existing hypertension complicating childbirth
O10.93 Unspecified pre-existing hypertension complicating the puerperium
O11.1 Pre-existing hypertension with pre-eclampsia, first trimester
O11.2 Pre-existing hypertension with pre-eclampsia, second trimester
O11.3 Pre-existing hypertension with pre-eclampsia, third trimester
O11.4 Pre-existing hypertension with pre-eclampsia, complicating childbirth
O11.5 Pre-existing hypertension with pre-eclampsia, complicating the puerperium
O11.9 Pre-existing hypertension with pre-eclampsia, unspecified trimester
O12.00 Gestational edema, unspecified trimester
O12.01 Gestational edema, first trimester
O12.02 Gestational edema, second trimester
O12.03 Gestational edema, third trimester
O12.04 Gestational edema, complicating childbirth
O12.05 Gestational edema, complicating the puerperium
O12.10 Gestational proteinuria, unspecified trimester
O12.11 Gestational proteinuria, first trimester
O12.12 Gestational proteinuria, second trimester
O12.13 Gestational proteinuria, third trimester
O12.20 Gestational edema with proteinuria, unspecified trimester
O12.21 Gestational edema with proteinuria, first trimester
O12.22 Gestational edema with proteinuria, second trimester
O12.23 Gestational edema with proteinuria, third trimester
O12.24 Gestational edema with proteinuria, complicating childbirth
O12.25 Gestational edema with proteinuria, complicating the puerperium
O13.1 Gestational [pregnancy-induced] hypertension without significant proteinuria, first trimester
O13.2 Gestational [pregnancy-induced] hypertension without significant proteinuria, second trimester
O13.3 Gestational [pregnancy-induced] hypertension without significant proteinuria, third trimester
O13.4 Gestational [pregnancy-induced] hypertension without significant proteinuria, complicating childbirth
O13.5 Gestational [pregnancy-induced] hypertension without significant proteinuria, complicating the puerperium
O13.9 Gestational [pregnancy-induced] hypertension without significant proteinuria, unspecified trimester
O14.00 Mild to moderate pre-eclampsia, unspecified trimester
O14.02 Mild to moderate pre-eclampsia, second trimester
O14.03 Mild to moderate pre-eclampsia, third trimester
O14.04 Mild to moderate pre-eclampsia, complicating childbirth
O14.05 Mild to moderate pre-eclampsia, complicating the puerperium
O14.10 Severe pre-eclampsia, unspecified trimester
O14.12 Severe pre-eclampsia, second trimester
O14.13 Severe pre-eclampsia, third trimester
O14.14 Severe pre-eclampsia complicating childbirth
O14.15 Severe pre-eclampsia, complicating the puerperium
O14.20 HELLP syndrome (HELLP), unspecified trimester
O14.22 HELLP syndrome (HELLP), second trimester
O14.23 HELLP syndrome (HELLP), third trimester
O14.24 HELLP syndrome, complicating childbirth
O14.25 HELLP syndrome, complicating the puerperium
O14.90 Unspecified pre-eclampsia, unspecified trimester
O14.92 Unspecified pre-eclampsia, second trimester
O14.93 Unspecified pre-eclampsia, third trimester
O14.94 Unspecified pre-eclampsia, complicating childbirth
O14.95 Unspecified pre-eclampsia, complicating the puerperium
O15.02 Eclampsia complicating pregnancy, second trimester
O15.03 Eclampsia complicating pregnancy, third trimester
O15.1 Eclampsia complicating labor
O15.2 Eclampsia complicating the puerperium
O16.1 Unspecified maternal hypertension, first trimester
O16.2 Unspecified maternal hypertension, second trimester
O16.3 Unspecified maternal hypertension, third trimester
O16.4 Unspecified maternal hypertension, complicating childbirth
O16.5 Unspecified maternal hypertension, complicating the puerperium
O16.9 Unspecified maternal hypertension, unspecified trimester
O20.0 Threatened abortion
O20.8 Other hemorrhage in early pregnancy
O20.9 Hemorrhage in early pregnancy, unspecified
O21.0 Mild hyperemesis gravidarum
O21.2 Late vomiting of pregnancy
O21.8 Other vomiting complicating pregnancy
O21.9 Vomiting of pregnancy, unspecified
O22.00 Varicose veins of lower extremity in pregnancy, unspecified trimester
O22.01 Varicose veins of lower extremity in pregnancy, first trimester
O22.02 Varicose veins of lower extremity in pregnancy, second trimester
O22.03 Varicose veins of lower extremity in pregnancy, third trimester
O22.10 Genital varices in pregnancy, unspecified trimester
O22.11 Genital varices in pregnancy, first trimester
O22.12 Genital varices in pregnancy, second trimester
O22.13 Genital varices in pregnancy, third trimester
O22.20 Superficial thrombophlebitis in pregnancy, unspecified trimester
O22.21 Superficial thrombophlebitis in pregnancy, first trimester
O22.22 Superficial thrombophlebitis in pregnancy, second trimester
O22.23 Superficial thrombophlebitis in pregnancy, third trimester
O22.30 Deep phlebothrombosis in pregnancy, unspecified trimester
O22.31 Deep phlebothrombosis in pregnancy, first trimester
O22.32 Deep phlebothrombosis in pregnancy, second trimester
O22.33 Deep phlebothrombosis in pregnancy, third trimester
O22.40 Hemorrhoids in pregnancy, unspecified trimester
O22.41 Hemorrhoids in pregnancy, first trimester
O22.42 Hemorrhoids in pregnancy, second trimester
O22.43 Hemorrhoids in pregnancy, third trimester
O22.50 Cerebral venous thrombosis in pregnancy, unspecified trimester
O22.51 Cerebral venous thrombosis in pregnancy, first trimester
O22.52 Cerebral venous thrombosis in pregnancy, second trimester
O22.53 Cerebral venous thrombosis in pregnancy, third trimester
O22.90 Venous complication in pregnancy, unspecified, unspecified trimester
O22.91 Venous complication in pregnancy, unspecified, first trimester
O22.92 Venous complication in pregnancy, unspecified, second trimester
O22.93 Venous complication in pregnancy, unspecified, third trimester
O23.00 Infections of kidney in pregnancy, unspecified trimester
O23.10 Infections of bladder in pregnancy, unspecified trimester
O23.20 Infections of urethra in pregnancy, unspecified trimester
O23.30 Infections of other parts of urinary tract in pregnancy, unspecified trimester
O23.40 Unspecified infection of urinary tract in pregnancy, unspecified trimester
O23.41 Unspecified infection of urinary tract in pregnancy, first trimester
O23.42 Unspecified infection of urinary tract in pregnancy, second trimester
O23.43 Unspecified infection of urinary tract in pregnancy, third trimester
O23.519 Infections of cervix in pregnancy, unspecified trimester
O23.529 Salpingo-oophoritis in pregnancy, unspecified trimester
O23.599 Infection of other part of genital tract in pregnancy, unspecified trimester
O23.90 Unspecified genitourinary tract infection in pregnancy, unspecified trimester
O23.91 Unspecified genitourinary tract infection in pregnancy, first trimester
O23.92 Unspecified genitourinary tract infection in pregnancy, second trimester
O23.93 Unspecified genitourinary tract infection in pregnancy, third trimester
O24.319 Unspecified pre-existing diabetes mellitus in pregnancy, unspecified trimester
O24.32 Unspecified pre-existing diabetes mellitus in childbirth
O24.415 Gestational diabetes mellitus in pregnancy, controlled by oral hypoglycemic drugs
O24.419 Gestational diabetes mellitus in pregnancy, unspecified control
O24.425 Gestational diabetes mellitus in childbirth, controlled by oral hypoglycemic drugs
O24.429 Gestational diabetes mellitus in childbirth, unspecified control
O24.435 Gestational diabetes mellitus in puerperium, controlled by oral hypoglycemic drugs
O24.439 Gestational diabetes mellitus in the puerperium, unspecified control
O24.911 Unspecified diabetes mellitus in pregnancy, first trimester
O24.912 Unspecified diabetes mellitus in pregnancy, second trimester
O24.913 Unspecified diabetes mellitus in pregnancy, third trimester
O24.92 Unspecified diabetes mellitus in childbirth
O24.93 Unspecified diabetes mellitus in the puerperium
O25.10 Malnutrition in pregnancy, unspecified trimester
O25.11 Malnutrition in pregnancy, first trimester
O25.12 Malnutrition in pregnancy, second trimester
O25.13 Malnutrition in pregnancy, third trimester
O25.2 Malnutrition in childbirth
O25.3 Malnutrition in the puerperium
O26.00 Excessive weight gain in pregnancy, unspecified trimester
O26.01 Excessive weight gain in pregnancy, first trimester
O26.02 Excessive weight gain in pregnancy, second trimester
O26.03 Excessive weight gain in pregnancy, third trimester
O26.11 Low weight gain in pregnancy, first trimester
O26.12 Low weight gain in pregnancy, second trimester
O26.13 Low weight gain in pregnancy, third trimester
O26.20 Pregnancy care for patient with recurrent pregnancy loss, unspecified trimester
O26.21 Pregnancy care for patient with recurrent pregnancy loss, first trimester
O26.22 Pregnancy care for patient with recurrent pregnancy loss, second trimester
O26.23 Pregnancy care for patient with recurrent pregnancy loss, third trimester
O26.41 Herpes gestationis, first trimester
O26.42 Herpes gestationis, second trimester
O26.43 Herpes gestationis, third trimester
O26.50 Maternal hypotension syndrome, unspecified trimester
O26.51 Maternal hypotension syndrome, first trimester
O26.52 Maternal hypotension syndrome, second trimester
O26.53 Maternal hypotension syndrome, third trimester
O26.611 Liver and biliary tract disorders in pregnancy, first trimester
O26.612 Liver and biliary tract disorders in pregnancy, second trimester
O26.613 Liver and biliary tract disorders in pregnancy, third trimester
O26.619 Liver and biliary tract disorders in pregnancy, unspecified trimester
O26.62 Liver and biliary tract disorders in childbirth
O26.811 Pregnancy related exhaustion and fatigue, first trimester
O26.812 Pregnancy related exhaustion and fatigue, second trimester
O26.813 Pregnancy related exhaustion and fatigue, third trimester
O26.819 Pregnancy related exhaustion and fatigue, unspecified trimester
O26.821 Pregnancy related peripheral neuritis, first trimester
O26.822 Pregnancy related peripheral neuritis, second trimester
O26.823 Pregnancy related peripheral neuritis, third trimester
O26.829 Pregnancy related peripheral neuritis, unspecified trimester
O26.831 Pregnancy related renal disease, first trimester
O26.832 Pregnancy related renal disease, second trimester
O26.833 Pregnancy related renal disease, third trimester
O26.839 Pregnancy related renal disease, unspecified trimester
O26.841 Uterine size-date discrepancy, first trimester
O26.842 Uterine size-date discrepancy, second trimester
O26.843 Uterine size-date discrepancy, third trimester
O26.849 Uterine size-date discrepancy, unspecified trimester
O26.851 Spotting complicating pregnancy, first trimester
O26.852 Spotting complicating pregnancy, second trimester
O26.853 Spotting complicating pregnancy, third trimester
O26.859 Spotting complicating pregnancy, unspecified trimester
O26.872 Cervical shortening, second trimester
O26.873 Cervical shortening, third trimester
O26.879 Cervical shortening, unspecified trimester
O26.891 Other specified pregnancy related conditions, first trimester
O26.892 Other specified pregnancy related conditions, second trimester
O26.893 Other specified pregnancy related conditions, third trimester
O26.899 Other specified pregnancy related conditions, unspecified trimester
O26.90 Pregnancy related conditions, unspecified, unspecified trimester
O30.001 Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, first trimester
O30.002 Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, second trimester
O30.003 Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, third trimester
O30.009 Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, unspecified trimester
O30.021 Conjoined twin pregnancy, first trimester
O30.022 Conjoined twin pregnancy, second trimester
O30.023 Conjoined twin pregnancy, third trimester
O30.029 Conjoined twin pregnancy, unspecified trimester
O30.101 Triplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, first trimester
O30.102 Triplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, second trimester
O30.103 Triplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, third trimester
O30.109 Triplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, unspecified trimester
O30.201 Quadruplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, first trimester
O30.202 Quadruplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, second trimester
O30.203 Quadruplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, third trimester
O30.209 Quadruplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, unspecified trimester
O30.801 Other specified multiple gestation, unspecified number of placenta and unspecified number of amniotic sacs, first trimester
O30.802 Other specified multiple gestation, unspecified number of placenta and unspecified number of amniotic sacs, second trimester
O30.803 Other specified multiple gestation, unspecified number of placenta and unspecified number of amniotic sacs, third trimester
O30.809 Other specified multiple gestation, unspecified number of placenta and unspecified number of amniotic sacs, unspecified trimester
O30.90 Multiple gestation, unspecified, unspecified trimester
O30.91 Multiple gestation, unspecified, first trimester
O30.92 Multiple gestation, unspecified, second trimester
O30.93 Multiple gestation, unspecified, third trimester
O33.0 Maternal care for disproportion due to deformity of maternal pelvic bones
O33.1 Maternal care for disproportion due to generally contracted pelvis
O33.2 Maternal care for disproportion due to inlet contraction of pelvis
O33.7XX0 Maternal care for disproportion due to other fetal deformities, not applicable or unspecified
O33.7XX1 Maternal care for disproportion due to other fetal deformities, fetus 1
O33.7XX2 Maternal care for disproportion due to other fetal deformities, fetus 2
O33.7XX3 Maternal care for disproportion due to other fetal deformities, fetus 3
O33.7XX4 Maternal care for disproportion due to other fetal deformities, fetus 4
O33.7XX5 Maternal care for disproportion due to other fetal deformities, fetus 5
O33.7XX9 Maternal care for disproportion due to other fetal deformities, other fetus
O33.8 Maternal care for disproportion of other origin
O33.9 Maternal care for disproportion, unspecified
O34.00 Maternal care for unspecified congenital malformation of uterus, unspecified trimester
O34.01 Maternal care for unspecified congenital malformation of uterus, first trimester
O34.02 Maternal care for unspecified congenital malformation of uterus, second trimester
O34.03 Maternal care for unspecified congenital malformation of uterus, third trimester
O34.10 Maternal care for benign tumor of corpus uteri, unspecified trimester
O34.11 Maternal care for benign tumor of corpus uteri, first trimester
O34.12 Maternal care for benign tumor of corpus uteri, second trimester
O34.13 Maternal care for benign tumor of corpus uteri, third trimester
O34.211 Maternal care for low transverse scar from previous cesarean delivery
O34.212 Maternal care for vertical scar from previous cesarean delivery
O34.218 Maternal care for other type scar from previous cesarean delivery
O34.219 Maternal care for unspecified type scar from previous cesarean delivery
O34.22 Maternal care for cesarean scar defect (isthmocele)
O34.29 Maternal care due to uterine scar from other previous surgery
O34.30 Maternal care for cervical incompetence, unspecified trimester
O34.31 Maternal care for cervical incompetence, first trimester
O34.32 Maternal care for cervical incompetence, second trimester
O34.33 Maternal care for cervical incompetence, third trimester
O34.40 Maternal care for other abnormalities of cervix, unspecified trimester
O34.41 Maternal care for other abnormalities of cervix, first trimester
O34.42 Maternal care for other abnormalities of cervix, second trimester
O34.43 Maternal care for other abnormalities of cervix, third trimester
O34.511 Maternal care for incarceration of gravid uterus, first trimester
O34.512 Maternal care for incarceration of gravid uterus, second trimester
O34.513 Maternal care for incarceration of gravid uterus, third trimester
O34.519 Maternal care for incarceration of gravid uterus, unspecified trimester
O34.521 Maternal care for prolapse of gravid uterus, first trimester
O34.522 Maternal care for prolapse of gravid uterus, second trimester
O34.523 Maternal care for prolapse of gravid uterus, third trimester
O34.529 Maternal care for prolapse of gravid uterus, unspecified trimester
O34.531 Maternal care for retroversion of gravid uterus, first trimester
O34.532 Maternal care for retroversion of gravid uterus, second trimester
O34.533 Maternal care for retroversion of gravid uterus, third trimester
O34.539 Maternal care for retroversion of gravid uterus, unspecified trimester
O34.591 Maternal care for other abnormalities of gravid uterus, first trimester
O34.592 Maternal care for other abnormalities of gravid uterus, second trimester
O34.593 Maternal care for other abnormalities of gravid uterus, third trimester
O34.599 Maternal care for other abnormalities of gravid uterus, unspecified trimester
O34.60 Maternal care for abnormality of vagina, unspecified trimester
O34.61 Maternal care for abnormality of vagina, first trimester
O34.62 Maternal care for abnormality of vagina, second trimester
O34.63 Maternal care for abnormality of vagina, third trimester
O34.70 Maternal care for abnormality of vulva and perineum, unspecified trimester
O34.71 Maternal care for abnormality of vulva and perineum, first trimester
O34.72 Maternal care for abnormality of vulva and perineum, second trimester
O34.73 Maternal care for abnormality of vulva and perineum, third trimester
O34.80 Maternal care for other abnormalities of pelvic organs, unspecified trimester
O34.81 Maternal care for other abnormalities of pelvic organs, first trimester
O34.82 Maternal care for other abnormalities of pelvic organs, second trimester
O34.83 Maternal care for other abnormalities of pelvic organs, third trimester
O34.90 Maternal care for abnormality of pelvic organ, unspecified, unspecified trimester
O34.91 Maternal care for abnormality of pelvic organ, unspecified, first trimester
O34.92 Maternal care for abnormality of pelvic organ, unspecified, second trimester
O34.93 Maternal care for abnormality of pelvic organ, unspecified, third trimester
O35.7XX0 Maternal care for (suspected) damage to fetus by other medical procedures, not applicable or unspecified
O35.7XX1 Maternal care for (suspected) damage to fetus by other medical procedures, fetus 1
O35.7XX2 Maternal care for (suspected) damage to fetus by other medical procedures, fetus 2
O35.7XX3 Maternal care for (suspected) damage to fetus by other medical procedures, fetus 3
O35.7XX4 Maternal care for (suspected) damage to fetus by other medical procedures, fetus 4
O35.7XX5 Maternal care for (suspected) damage to fetus by other medical procedures, fetus 5
O35.7XX9 Maternal care for (suspected) damage to fetus by other medical procedures, other fetus
O35.8XX0 Maternal care for other (suspected) fetal abnormality and damage, not applicable or unspecified
O35.8XX1 Maternal care for other (suspected) fetal abnormality and damage, fetus 1
O35.8XX2 Maternal care for other (suspected) fetal abnormality and damage, fetus 2
O35.8XX3 Maternal care for other (suspected) fetal abnormality and damage, fetus 3
O35.8XX4 Maternal care for other (suspected) fetal abnormality and damage, fetus 4
O35.8XX5 Maternal care for other (suspected) fetal abnormality and damage, fetus 5
O35.8XX9 Maternal care for other (suspected) fetal abnormality and damage, other fetus
O36.0110 Maternal care for anti-D [Rh] antibodies, first trimester, not applicable or unspecified
O36.0120 Maternal care for anti-D [Rh] antibodies, second trimester, not applicable or unspecified
O36.0130 Maternal care for anti-D [Rh] antibodies, third trimester, not applicable or unspecified
O36.0190 Maternal care for anti-D [Rh] antibodies, unspecified trimester, not applicable or unspecified
O36.0910 Maternal care for other rhesus isoimmunization, first trimester, not applicable or unspecified
O36.0920 Maternal care for other rhesus isoimmunization, second trimester, not applicable or unspecified
O36.0930 Maternal care for other rhesus isoimmunization, third trimester, not applicable or unspecified
O36.0990 Maternal care for other rhesus isoimmunization, unspecified trimester, not applicable or unspecified
O36.1110 Maternal care for Anti-A sensitization, first trimester, not applicable or unspecified
O36.1120 Maternal care for Anti-A sensitization, second trimester, not applicable or unspecified
O36.1130 Maternal care for Anti-A sensitization, third trimester, not applicable or unspecified
O36.1190 Maternal care for Anti-A sensitization, unspecified trimester, not applicable or unspecified
O36.1910 Maternal care for other isoimmunization, first trimester, not applicable or unspecified
O36.1920 Maternal care for other isoimmunization, second trimester, not applicable or unspecified
O36.1930 Maternal care for other isoimmunization, third trimester, not applicable or unspecified
O36.1990 Maternal care for other isoimmunization, unspecified trimester, not applicable or unspecified
O36.5110 Maternal care for known or suspected placental insufficiency, first trimester, not applicable or unspecified
O36.5120 Maternal care for known or suspected placental insufficiency, second trimester, not applicable or unspecified
O36.5130 Maternal care for known or suspected placental insufficiency, third trimester, not applicable or unspecified
O36.5190 Maternal care for known or suspected placental insufficiency, unspecified trimester, not applicable or unspecified
O36.5910 Maternal care for other known or suspected poor fetal growth, first trimester, not applicable or unspecified
O36.5920 Maternal care for other known or suspected poor fetal growth, second trimester, not applicable or unspecified
O36.5930 Maternal care for other known or suspected poor fetal growth, third trimester, not applicable or unspecified
O36.5990 Maternal care for other known or suspected poor fetal growth, unspecified trimester, not applicable or unspecified
O36.8120 Decreased fetal movements, second trimester, not applicable or unspecified
O36.8130 Decreased fetal movements, third trimester, not applicable or unspecified
O36.8190 Decreased fetal movements, unspecified trimester, not applicable or unspecified
O36.8210 Fetal anemia and thrombocytopenia, first trimester, not applicable or unspecified
O36.8220 Fetal anemia and thrombocytopenia, second trimester, not applicable or unspecified
O36.8230 Fetal anemia and thrombocytopenia, third trimester, not applicable or unspecified
O36.8290 Fetal anemia and thrombocytopenia, unspecified trimester, not applicable or unspecified
O36.8910 Maternal care for other specified fetal problems, first trimester, not applicable or unspecified
O36.8920 Maternal care for other specified fetal problems, second trimester, not applicable or unspecified
O36.8930 Maternal care for other specified fetal problems, third trimester, not applicable or unspecified
O36.8990 Maternal care for other specified fetal problems, unspecified trimester, not applicable or unspecified
O41.1010 Infection of amniotic sac and membranes, unspecified, first trimester, not applicable or unspecified
O41.1020 Infection of amniotic sac and membranes, unspecified, second trimester, not applicable or unspecified
O41.1030 Infection of amniotic sac and membranes, unspecified, third trimester, not applicable or unspecified
O41.1090 Infection of amniotic sac and membranes, unspecified, unspecified trimester, not applicable or unspecified
O41.1210 Chorioamnionitis, first trimester, not applicable or unspecified
O41.1220 Chorioamnionitis, second trimester, not applicable or unspecified
O41.1230 Chorioamnionitis, third trimester, not applicable or unspecified
O41.1290 Chorioamnionitis, unspecified trimester, not applicable or unspecified
O41.1410 Placentitis, first trimester, not applicable or unspecified
O41.1420 Placentitis, second trimester, not applicable or unspecified
O41.1430 Placentitis, third trimester, not applicable or unspecified
O41.1490 Placentitis, unspecified trimester, not applicable or unspecified
O42.00 Premature rupture of membranes, onset of labor within 24 hours of rupture, unspecified weeks of gestation
O42.011 Preterm premature rupture of membranes, onset of labor within 24 hours of rupture, first trimester
O42.012 Preterm premature rupture of membranes, onset of labor within 24 hours of rupture, second trimester
O42.013 Preterm premature rupture of membranes, onset of labor within 24 hours of rupture, third trimester
O42.02 Full-term premature rupture of membranes, onset of labor within 24 hours of rupture
O42.10 Premature rupture of membranes, onset of labor more than 24 hours following rupture, unspecified weeks of gestation
O42.111 Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, first trimester
O42.112 Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, second trimester
O42.113 Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, third trimester
O42.12 Full-term premature rupture of membranes, onset of labor more than 24 hours following rupture
O43.011 Fetomaternal placental transfusion syndrome, first trimester
O43.019 Fetomaternal placental transfusion syndrome, unspecified trimester
O43.101 Malformation of placenta, unspecified, first trimester
O43.102 Malformation of placenta, unspecified, second trimester
O43.103 Malformation of placenta, unspecified, third trimester
O43.199 Other malformation of placenta, unspecified trimester
O43.211 Placenta accreta, first trimester
O43.212 Placenta accreta, second trimester
O43.213 Placenta accreta, third trimester
O43.221 Placenta increta, first trimester
O43.222 Placenta increta, second trimester
O43.223 Placenta increta, third trimester
O43.231 Placenta percreta, first trimester
O43.232 Placenta percreta, second trimester
O43.233 Placenta percreta, third trimester
O43.239 Placenta percreta, unspecified trimester
O43.811 Placental infarction, first trimester
O43.812 Placental infarction, second trimester
O43.813 Placental infarction, third trimester
O43.819 Placental infarction, unspecified trimester
O43.91 Unspecified placental disorder, first trimester
O43.92 Unspecified placental disorder, second trimester
O43.93 Unspecified placental disorder, third trimester
O44.00 Complete placenta previa NOS or without hemorrhage, unspecified trimester
O44.01 Complete placenta previa NOS or without hemorrhage, first trimester
O44.02 Complete placenta previa NOS or without hemorrhage, second trimester
O44.03 Complete placenta previa NOS or without hemorrhage, third trimester
O44.10 Complete placenta previa with hemorrhage, unspecified trimester
O44.11 Complete placenta previa with hemorrhage, first trimester
O44.12 Complete placenta previa with hemorrhage, second trimester
O44.13 Complete placenta previa with hemorrhage, third trimester
O44.20 Partial placenta previa NOS or without hemorrhage, unspecified trimester
O44.21 Partial placenta previa NOS or without hemorrhage, first trimester
O44.22 Partial placenta previa NOS or without hemorrhage, second trimester
O44.23 Partial placenta previa NOS or without hemorrhage, third trimester
O44.30 Partial placenta previa with hemorrhage, unspecified trimester
O44.31 Partial placenta previa with hemorrhage, first trimester
O44.32 Partial placenta previa with hemorrhage, second trimester
O44.33 Partial placenta previa with hemorrhage, third trimester
O44.40 Low lying placenta NOS or without hemorrhage, unspecified trimester
O44.41 Low lying placenta NOS or without hemorrhage, first trimester
O44.42 Low lying placenta NOS or without hemorrhage, second trimester
O44.43 Low lying placenta NOS or without hemorrhage, third trimester
O44.50 Low lying placenta with hemorrhage, unspecified trimester
O44.51 Low lying placenta with hemorrhage, first trimester
O44.52 Low lying placenta with hemorrhage, second trimester
O44.53 Low lying placenta with hemorrhage, third trimester
O45.001 Premature separation of placenta with coagulation defect, unspecified, first trimester
O45.002 Premature separation of placenta with coagulation defect, unspecified, second trimester
O45.003 Premature separation of placenta with coagulation defect, unspecified, third trimester
O45.011 Premature separation of placenta with afibrinogenemia, first trimester
O45.012 Premature separation of placenta with afibrinogenemia, second trimester
O45.013 Premature separation of placenta with afibrinogenemia, third trimester
O45.021 Premature separation of placenta with disseminated intravascular coagulation, first trimester
O45.022 Premature separation of placenta with disseminated intravascular coagulation, second trimester
O45.023 Premature separation of placenta with disseminated intravascular coagulation, third trimester
O45.091 Premature separation of placenta with other coagulation defect, first trimester
O45.092 Premature separation of placenta with other coagulation defect, second trimester
O45.093 Premature separation of placenta with other coagulation defect, third trimester
O45.91 Premature separation of placenta, unspecified, first trimester
O45.92 Premature separation of placenta, unspecified, second trimester
O45.93 Premature separation of placenta, unspecified, third trimester
O46.001 Antepartum hemorrhage with coagulation defect, unspecified, first trimester
O46.002 Antepartum hemorrhage with coagulation defect, unspecified, second trimester
O46.003 Antepartum hemorrhage with coagulation defect, unspecified, third trimester
O46.009 Antepartum hemorrhage with coagulation defect, unspecified, unspecified trimester
O46.011 Antepartum hemorrhage with afibrinogenemia, first trimester
O46.012 Antepartum hemorrhage with afibrinogenemia, second trimester
O46.013 Antepartum hemorrhage with afibrinogenemia, third trimester
O46.019 Antepartum hemorrhage with afibrinogenemia, unspecified trimester
O46.021 Antepartum hemorrhage with disseminated intravascular coagulation, first trimester
O46.022 Antepartum hemorrhage with disseminated intravascular coagulation, second trimester
O46.023 Antepartum hemorrhage with disseminated intravascular coagulation, third trimester
O46.029 Antepartum hemorrhage with disseminated intravascular coagulation, unspecified trimester
O46.091 Antepartum hemorrhage with other coagulation defect, first trimester
O46.092 Antepartum hemorrhage with other coagulation defect, second trimester
O46.093 Antepartum hemorrhage with other coagulation defect, third trimester
O46.099 Antepartum hemorrhage with other coagulation defect, unspecified trimester
O46.90 Antepartum hemorrhage, unspecified, unspecified trimester
O46.91 Antepartum hemorrhage, unspecified, first trimester
O46.92 Antepartum hemorrhage, unspecified, second trimester
O46.93 Antepartum hemorrhage, unspecified, third trimester
O47.00 False labor before 37 completed weeks of gestation, unspecified trimester
O47.02 False labor before 37 completed weeks of gestation, second trimester
O47.03 False labor before 37 completed weeks of gestation, third trimester
O47.1 False labor at or after 37 completed weeks of gestation
O47.9 False labor, unspecified
O48.0 Post-term pregnancy
O48.1 Prolonged pregnancy
O60.00 Preterm labor without delivery, unspecified trimester
O60.02 Preterm labor without delivery, second trimester
O60.03 Preterm labor without delivery, third trimester
O61.0 Failed medical induction of labor
O61.1 Failed instrumental induction of labor
O61.9 Failed induction of labor, unspecified
O62.0 Primary inadequate contractions
O62.1 Secondary uterine inertia
O62.2 Other uterine inertia
O62.3 Precipitate labor
O62.4 Hypertonic, incoordinate, and prolonged uterine contractions
O62.9 Abnormality of forces of labor, unspecified
O63.0 Prolonged first stage (of labor)
O63.1 Prolonged second stage (of labor)
O63.2 Delayed delivery of second twin, triplet, etc.
O63.9 Long labor, unspecified
O65.4 Obstructed labor due to fetopelvic disproportion, unspecified
O65.5 Obstructed labor due to abnormality of maternal pelvic organs
O65.9 Obstructed labor due to maternal pelvic abnormality, unspecified
O66.0 Obstructed labor due to shoulder dystocia
O66.1 Obstructed labor due to locked twins
O66.40 Failed trial of labor, unspecified
O66.5 Attempted application of vacuum extractor and forceps
O66.8 Other specified obstructed labor
O66.9 Obstructed labor, unspecified
O67.0 Intrapartum hemorrhage with coagulation defect
O67.8 Other intrapartum hemorrhage
O67.9 Intrapartum hemorrhage, unspecified
O68 Labor and delivery complicated by abnormality of fetal acid-base balance
O70.0 First degree perineal laceration during delivery
O70.1 Second degree perineal laceration during delivery
O70.20 Third degree perineal laceration during delivery, unspecified
O70.21 Third degree perineal laceration during delivery, IIIa
O70.22 Third degree perineal laceration during delivery, IIIb
O70.23 Third degree perineal laceration during delivery, IIIc
O70.3 Fourth degree perineal laceration during delivery
O70.4 Anal sphincter tear complicating delivery, not associated with third degree laceration
O70.9 Perineal laceration during delivery, unspecified
O71.00 Rupture of uterus before onset of labor, unspecified trimester
O71.02 Rupture of uterus before onset of labor, second trimester
O71.03 Rupture of uterus before onset of labor, third trimester
O71.1 Rupture of uterus during labor
O71.2 Postpartum inversion of uterus
O71.3 Obstetric laceration of cervix
O71.4 Obstetric high vaginal laceration alone
O71.5 Other obstetric injury to pelvic organs
O71.6 Obstetric damage to pelvic joints and ligaments
O71.7 Obstetric hematoma of pelvis
O71.82 Other specified trauma to perineum and vulva
O71.89 Other specified obstetric trauma
O71.9 Obstetric trauma, unspecified
O72.0 Third-stage hemorrhage
O72.1 Other immediate postpartum hemorrhage
O72.2 Delayed and secondary postpartum hemorrhage
O72.3 Postpartum coagulation defects
O73.0 Retained placenta without hemorrhage
O73.1 Retained portions of placenta and membranes, without hemorrhage
O74.1 Other pulmonary complications of anesthesia during labor and delivery
O74.2 Cardiac complications of anesthesia during labor and delivery
O74.3 Central nervous system complications of anesthesia during labor and delivery
O74.8 Other complications of anesthesia during labor and delivery
O74.9 Complication of anesthesia during labor and delivery, unspecified
O75.0 Maternal distress during labor and delivery
O75.1 Shock during or following labor and delivery
O75.2 Pyrexia during labor, not elsewhere classified
O75.3 Other infection during labor
O75.4 Other complications of obstetric surgery and procedures
O75.5 Delayed delivery after artificial rupture of membranes
O75.81 Maternal exhaustion complicating labor and delivery
O75.89 Other specified complications of labor and delivery
O75.9 Complication of labor and delivery, unspecified
O76 Abnormality in fetal heart rate and rhythm complicating labor and delivery
O77.0 Labor and delivery complicated by meconium in amniotic fluid
O80 Encounter for full-term uncomplicated delivery
O82 Encounter for cesarean delivery without indication
O85 Puerperal sepsis
O86.00 Infection of obstetric surgical wound, unspecified
O86.01 Infection of obstetric surgical wound, superficial incisional site
O86.02 Infection of obstetric surgical wound, deep incisional site
O86.03 Infection of obstetric surgical wound, organ and space site
O86.04 Sepsis following an obstetrical procedure
O86.09 Infection of obstetric surgical wound, other surgical site
O86.11 Cervicitis following delivery
O86.12 Endometritis following delivery
O86.13 Vaginitis following delivery
O86.19 Other infection of genital tract following delivery
O86.20 Urinary tract infection following delivery, unspecified
O86.21 Infection of kidney following delivery
O86.22 Infection of bladder following delivery
O86.29 Other urinary tract infection following delivery
O86.4 Pyrexia of unknown origin following delivery
O86.81 Puerperal septic thrombophlebitis
O86.89 Other specified puerperal infections
O87.0 Superficial thrombophlebitis in the puerperium
O87.1 Deep phlebothrombosis in the puerperium
O87.2 Hemorrhoids in the puerperium
O87.3 Cerebral venous thrombosis in the puerperium
O87.4 Varicose veins of lower extremity in the puerperium
O87.8 Other venous complications in the puerperium
O87.9 Venous complication in the puerperium, unspecified
O88.011 Air embolism in pregnancy, first trimester
O88.012 Air embolism in pregnancy, second trimester
O88.013 Air embolism in pregnancy, third trimester
O88.019 Air embolism in pregnancy, unspecified trimester
O88.02 Air embolism in childbirth
O88.03 Air embolism in the puerperium
O88.111 Amniotic fluid embolism in pregnancy, first trimester
O88.112 Amniotic fluid embolism in pregnancy, second trimester
O88.113 Amniotic fluid embolism in pregnancy, third trimester
O88.119 Amniotic fluid embolism in pregnancy, unspecified trimester
O88.12 Amniotic fluid embolism in childbirth
O88.13 Amniotic fluid embolism in the puerperium
O88.211 Thromboembolism in pregnancy, first trimester
O88.212 Thromboembolism in pregnancy, second trimester
O88.213 Thromboembolism in pregnancy, third trimester
O88.219 Thromboembolism in pregnancy, unspecified trimester
O88.22 Thromboembolism in childbirth
O88.23 Thromboembolism in the puerperium
O88.311 Pyemic and septic embolism in pregnancy, first trimester
O88.312 Pyemic and septic embolism in pregnancy, second trimester
O88.313 Pyemic and septic embolism in pregnancy, third trimester
O88.319 Pyemic and septic embolism in pregnancy, unspecified trimester
O88.32 Pyemic and septic embolism in childbirth
O88.33 Pyemic and septic embolism in the puerperium
O88.811 Other embolism in pregnancy, first trimester
O88.812 Other embolism in pregnancy, second trimester
O88.813 Other embolism in pregnancy, third trimester
O88.819 Other embolism in pregnancy, unspecified trimester
O88.82 Other embolism in childbirth
O88.83 Other embolism in the puerperium
O89.09 Other pulmonary complications of anesthesia during the puerperium
O89.1 Cardiac complications of anesthesia during the puerperium
O89.2 Central nervous system complications of anesthesia during the puerperium
O89.8 Other complications of anesthesia during the puerperium
O89.9 Complication of anesthesia during the puerperium, unspecified
O90.0 Disruption of cesarean delivery wound
O90.1 Disruption of perineal obstetric wound
O90.2 Hematoma of obstetric wound
O90.3 Peripartum cardiomyopathy
O90.4 Postpartum acute kidney failure
O90.5 Postpartum thyroiditis
O90.6 Postpartum mood disturbance
O90.81 Anemia of the puerperium
O90.89 Other complications of the puerperium, not elsewhere classified
O90.9 Complication of the puerperium, unspecified
O91.011 Infection of nipple associated with pregnancy, first trimester
O91.012 Infection of nipple associated with pregnancy, second trimester
O91.013 Infection of nipple associated with pregnancy, third trimester
O91.019 Infection of nipple associated with pregnancy, unspecified trimester
O91.02 Infection of nipple associated with the puerperium
O91.111 Abscess of breast associated with pregnancy, first trimester
O91.112 Abscess of breast associated with pregnancy, second trimester
O91.113 Abscess of breast associated with pregnancy, third trimester
O91.119 Abscess of breast associated with pregnancy, unspecified trimester
O91.12 Abscess of breast associated with the puerperium
O91.211 Nonpurulent mastitis associated with pregnancy, first trimester
O91.212 Nonpurulent mastitis associated with pregnancy, second trimester
O91.213 Nonpurulent mastitis associated with pregnancy, third trimester
O91.219 Nonpurulent mastitis associated with pregnancy, unspecified trimester
O91.22 Nonpurulent mastitis associated with the puerperium
O91.23 Nonpurulent mastitis associated with lactation
O92.011 Retracted nipple associated with pregnancy, first trimester
O92.012 Retracted nipple associated with pregnancy, second trimester
O92.013 Retracted nipple associated with pregnancy, third trimester
O92.019 Retracted nipple associated with pregnancy, unspecified trimester
O92.03 Retracted nipple associated with lactation
O92.111 Cracked nipple associated with pregnancy, first trimester
O92.112 Cracked nipple associated with pregnancy, second trimester
O92.113 Cracked nipple associated with pregnancy, third trimester
O92.119 Cracked nipple associated with pregnancy, unspecified trimester
O92.13 Cracked nipple associated with lactation
O92.20 Unspecified disorder of breast associated with pregnancy and the puerperium
O92.29 Other disorders of breast associated with pregnancy and the puerperium
O92.3 Agalactia
O92.5 Suppressed lactation
O92.6 Galactorrhea
O92.70 Unspecified disorders of lactation
O92.79 Other disorders of lactation
O94 Sequelae of complication of pregnancy, childbirth, and the puerperium
O98.011 Tuberculosis complicating pregnancy, first trimester
O98.012 Tuberculosis complicating pregnancy, second trimester
O98.013 Tuberculosis complicating pregnancy, third trimester
O98.019 Tuberculosis complicating pregnancy, unspecified trimester
O98.02 Tuberculosis complicating childbirth
O98.03 Tuberculosis complicating the puerperium
O98.111 Syphilis complicating pregnancy, first trimester
O98.112 Syphilis complicating pregnancy, second trimester
O98.113 Syphilis complicating pregnancy, third trimester
O98.119 Syphilis complicating pregnancy, unspecified trimester
O98.12 Syphilis complicating childbirth
O98.13 Syphilis complicating the puerperium
O98.211 Gonorrhea complicating pregnancy, first trimester
O98.212 Gonorrhea complicating pregnancy, second trimester
O98.213 Gonorrhea complicating pregnancy, third trimester
O98.219 Gonorrhea complicating pregnancy, unspecified trimester
O98.22 Gonorrhea complicating childbirth
O98.23 Gonorrhea complicating the puerperium
O98.311 Other infections with a predominantly sexual mode of transmission complicating pregnancy, first trimester
O98.312 Other infections with a predominantly sexual mode of transmission complicating pregnancy, second trimester
O98.313 Other infections with a predominantly sexual mode of transmission complicating pregnancy, third trimester
O98.319 Other infections with a predominantly sexual mode of transmission complicating pregnancy, unspecified trimester
O98.32 Other infections with a predominantly sexual mode of transmission complicating childbirth
O98.33 Other infections with a predominantly sexual mode of transmission complicating the puerperium
O98.42 Viral hepatitis complicating childbirth
O98.43 Viral hepatitis complicating the puerperium
O98.511 Other viral diseases complicating pregnancy, first trimester
O98.512 Other viral diseases complicating pregnancy, second trimester
O98.513 Other viral diseases complicating pregnancy, third trimester
O98.519 Other viral diseases complicating pregnancy, unspecified trimester
O98.52 Other viral diseases complicating childbirth
O98.53 Other viral diseases complicating the puerperium
O98.611 Protozoal diseases complicating pregnancy, first trimester
O98.612 Protozoal diseases complicating pregnancy, second trimester
O98.613 Protozoal diseases complicating pregnancy, third trimester
O98.619 Protozoal diseases complicating pregnancy, unspecified trimester
O98.62 Protozoal diseases complicating childbirth
O98.63 Protozoal diseases complicating the puerperium
O98.811 Other maternal infectious and parasitic diseases complicating pregnancy, first trimester
O98.812 Other maternal infectious and parasitic diseases complicating pregnancy, second trimester
O98.813 Other maternal infectious and parasitic diseases complicating pregnancy, third trimester
O98.819 Other maternal infectious and parasitic diseases complicating pregnancy, unspecified trimester
O98.82 Other maternal infectious and parasitic diseases complicating childbirth
O98.83 Other maternal infectious and parasitic diseases complicating the puerperium
O98.911 Unspecified maternal infectious and parasitic disease complicating pregnancy, first trimester
O98.912 Unspecified maternal infectious and parasitic disease complicating pregnancy, second trimester
O98.913 Unspecified maternal infectious and parasitic disease complicating pregnancy, third trimester
O98.919 Unspecified maternal infectious and parasitic disease complicating pregnancy, unspecified trimester
O98.92 Unspecified maternal infectious and parasitic disease complicating childbirth
O98.93 Unspecified maternal infectious and parasitic disease complicating the puerperium
O99.011 Anemia complicating pregnancy, first trimester
O99.012 Anemia complicating pregnancy, second trimester
O99.013 Anemia complicating pregnancy, third trimester
O99.019 Anemia complicating pregnancy, unspecified trimester
O99.02 Anemia complicating childbirth
O99.03 Anemia complicating the puerperium
O99.111 Other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism complicating pregnancy, first trimester
O99.112 Other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism complicating pregnancy, second trimester
O99.113 Other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism complicating pregnancy, third trimester
O99.119 Other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism complicating pregnancy, unspecified trimester
O99.12 Other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism complicating childbirth
O99.13 Other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism complicating the puerperium
O99.210 Obesity complicating pregnancy, unspecified trimester
O99.211 Obesity complicating pregnancy, first trimester
O99.212 Obesity complicating pregnancy, second trimester
O99.213 Obesity complicating pregnancy, third trimester
O99.214 Obesity complicating childbirth
O99.215 Obesity complicating the puerperium
O99.280 Endocrine, nutritional and metabolic diseases complicating pregnancy, unspecified trimester
O99.281 Endocrine, nutritional and metabolic diseases complicating pregnancy, first trimester
O99.282 Endocrine, nutritional and metabolic diseases complicating pregnancy, second trimester
O99.283 Endocrine, nutritional and metabolic diseases complicating pregnancy, third trimester
O99.284 Endocrine, nutritional and metabolic diseases complicating childbirth
O99.285 Endocrine, nutritional and metabolic diseases complicating the puerperium
O99.320 Drug use complicating pregnancy, unspecified trimester
O99.321 Drug use complicating pregnancy, first trimester
O99.322 Drug use complicating pregnancy, second trimester
O99.323 Drug use complicating pregnancy, third trimester
O99.324 Drug use complicating childbirth
O99.325 Drug use complicating the puerperium
O99.330 Smoking (tobacco) complicating pregnancy, unspecified trimester
O99.331 Smoking (tobacco) complicating pregnancy, first trimester
O99.332 Smoking (tobacco) complicating pregnancy, second trimester
O99.333 Smoking (tobacco) complicating pregnancy, third trimester
O99.334 Smoking (tobacco) complicating childbirth
O99.335 Smoking (tobacco) complicating the puerperium
O99.340 Other mental disorders complicating pregnancy, unspecified trimester
O99.341 Other mental disorders complicating pregnancy, first trimester
O99.342 Other mental disorders complicating pregnancy, second trimester
O99.343 Other mental disorders complicating pregnancy, third trimester
O99.344 Other mental disorders complicating childbirth
O99.345 Other mental disorders complicating the puerperium
O99.350 Diseases of the nervous system complicating pregnancy, unspecified trimester
O99.351 Diseases of the nervous system complicating pregnancy, first trimester
O99.352 Diseases of the nervous system complicating pregnancy, second trimester
O99.353 Diseases of the nervous system complicating pregnancy, third trimester
O99.354 Diseases of the nervous system complicating childbirth
O99.355 Diseases of the nervous system complicating the puerperium
O99.411 Diseases of the circulatory system complicating pregnancy, first trimester
O99.412 Diseases of the circulatory system complicating pregnancy, second trimester
O99.413 Diseases of the circulatory system complicating pregnancy, third trimester
O99.419 Diseases of the circulatory system complicating pregnancy, unspecified trimester
O99.42 Diseases of the circulatory system complicating childbirth
O99.43 Diseases of the circulatory system complicating the puerperium
O99.810 Abnormal glucose complicating pregnancy
O99.814 Abnormal glucose complicating childbirth
O99.815 Abnormal glucose complicating the puerperium
O99.834 Other infection carrier state complicating childbirth
O99.835 Other infection carrier state complicating the puerperium
O99.840 Bariatric surgery status complicating pregnancy, unspecified trimester
O99.841 Bariatric surgery status complicating pregnancy, first trimester
O99.842 Bariatric surgery status complicating pregnancy, second trimester
O99.843 Bariatric surgery status complicating pregnancy, third trimester
O99.844 Bariatric surgery status complicating childbirth
O99.845 Bariatric surgery status complicating the puerperium
O99.891 Other specified diseases and conditions complicating pregnancy
O99.892 Other specified diseases and conditions complicating childbirth
O99.893 Other specified diseases and conditions complicating puerperium
Z33.1 Pregnant state, incidental
Z33.2 Encounter for elective termination of pregnancy
Z33.3 Pregnant state, gestational carrier
Z34.00 Encounter for supervision of normal first pregnancy, unspecified trimester
Z34.01 Encounter for supervision of normal first pregnancy, first trimester
Z34.02 Encounter for supervision of normal first pregnancy, second trimester
Z34.03 Encounter for supervision of normal first pregnancy, third trimester
Z34.80 Encounter for supervision of other normal pregnancy, unspecified trimester
Z34.81 Encounter for supervision of other normal pregnancy, first trimester
Z34.82 Encounter for supervision of other normal pregnancy, second trimester
Z34.83 Encounter for supervision of other normal pregnancy, third trimester
Z34.90 Encounter for supervision of normal pregnancy, unspecified, unspecified trimester
Z34.91 Encounter for supervision of normal pregnancy, unspecified, first trimester
Z34.92 Encounter for supervision of normal pregnancy, unspecified, second trimester
Z34.93 Encounter for supervision of normal pregnancy, unspecified, third trimester
Z36.0 Encounter for antenatal screening for chromosomal anomalies
Z36.1 Encounter for antenatal screening for raised alphafetoprotein level
Z36.2 Encounter for other antenatal screening follow-up
Z36.3 Encounter for antenatal screening for malformations
Z36.4 Encounter for antenatal screening for fetal growth retardation
Z36.5 Encounter for antenatal screening for isoimmunization
Z36.81 Encounter for antenatal screening for hydrops fetalis
Z36.82 Encounter for antenatal screening for nuchal translucency
Z36.84 Encounter for antenatal screening for fetal lung maturity
Z36.85 Encounter for antenatal screening for Streptococcus B
Z36.86 Encounter for antenatal screening for cervical length
Z36.87 Encounter for antenatal screening for uncertain dates
Z36.88 Encounter for antenatal screening for fetal macrosomia
Z36.89 Encounter for other specified antenatal screening
Z36.8A Encounter for antenatal screening for other genetic defects
Z36.9 Encounter for antenatal screening, unspecified

 

SNOMED:  
Code Description
10231000132102 In-vitro fertilization pregnancy (finding)
102872000 Pregnancy on oral contraceptive (finding)
102875003 Surrogate pregnancy (finding)
11082009 Abnormal pregnancy (finding)
127363001 Number of pregnancies, currently pregnant (finding)
127364007 Primigravida (finding)
134781000119106 High risk pregnancy due to recurrent miscarriage (finding)
14080002 Illegitimate pregnancy, life event (finding)
14418008 Precocious pregnancy (finding)
16356006 Multiple pregnancy (disorder)
16836261000119107 Ectopic pregnancy of left ovary (disorder)
16836351000119100 Ectopic pregnancy of right ovary (disorder)
16836391000119105 Pregnancy of left fallopian tube (disorder)
16836891000119104 Pregnancy of right fallopian tube (disorder)
169488004 Contraceptive intrauterine device failure – pregnant (finding)
169560008 Pregnant – urine test confirms (finding)
169561007 Pregnant – blood test confirms (finding)
169562000 Pregnant – vaginal examination confirms (finding)
169563005 Pregnant – on history (finding)
169564004 Pregnant – on abdominal palpation (finding)
169565003 Pregnant – planned (finding)
169566002 Pregnancy unplanned but wanted (finding)
169567006 Pregnancy unplanned and unwanted (finding)
169568001 Unplanned pregnancy unknown if child is wanted (finding)
17285009 Intraperitoneal pregnancy (disorder)
198624007 Membranous pregnancy (disorder)
198626009 Mesenteric pregnancy (disorder)
198627000 Angular pregnancy (disorder)
199064003 Post-term pregnancy – not delivered (disorder)
199306007 Continuing pregnancy after abortion of one fetus or more (disorder)
199715003 Grand multiparity with antenatal problem (finding)
22281000119101 Post-term pregnancy of 40 to 42 weeks (disorder)
237233002 Concealed pregnancy (finding)
237238006 Pregnancy with uncertain dates (finding)
237239003 Low risk pregnancy (finding)
237240001 Teenage pregnancy (finding)
237241002 Viable pregnancy (finding)
237242009 Non-viable pregnancy (finding)
237244005 Single pregnancy (finding)
237254009 Unruptured tubal pregnancy (disorder)
239101008 Pregnancy eruption (disorder)
248985009 Presentation of pregnancy (finding)
276367008 Wanted pregnancy (finding)
276881003 Secondary abdominal pregnancy (disorder)
281307002 Uncertain viability of pregnancy (finding)
29399001 Elderly primigravida (finding)
314204000 Early stage of pregnancy (finding)
31601007 Combined pregnancy (disorder)
34801009 Ectopic pregnancy (disorder)
35381000119101 Quadruplet pregnancy with loss of one or more fetuses (disorder)
35656003 Intraligamentous pregnancy (disorder)
36801000119105 Continuing triplet pregnancy after spontaneous abortion of one or more fetuses (disorder)
38720006 Septuplet pregnancy (disorder)
41587001 Third trimester pregnancy (finding)
41991004 Angiectasis pregnancy (disorder)
429187001 Continuing pregnancy after intrauterine death of twin fetus (disorder)
43990006 Sextuplet pregnancy (disorder)
442478007 Multiple pregnancy involving intrauterine pregnancy and tubal pregnancy (disorder)
444661007 High risk pregnancy due to history of preterm labor (finding)
44782008 Molar pregnancy (disorder)
45307008 Extrachorial pregnancy (finding)
457811000124103 Normal pregnancy in primigravida (finding)
457821000124106 Normal pregnancy in multigravida (finding)
459167000 Monochorionic twin pregnancy (disorder)
459169002 Monochorionic diamniotic twin pregnancy with similar amniotic fluid volumes (disorder)
459170001 Monochorionic diamniotic twin pregnancy with dissimilar amniotic fluid volumes (disorder)
47200007 High risk pregnancy (finding)
472321009 Continuing pregnancy after intrauterine death of one twin with intrauterine retention of dead twin (disorder)
57630001 First trimester pregnancy (finding)
58532003 Unwanted pregnancy (finding)
59466002 Second trimester pregnancy (finding)
60000008 Mesometric pregnancy (disorder)
60810003 Quadruplet pregnancy (disorder)
64254006 Triplet pregnancy (disorder)
65147003 Twin pregnancy (disorder)
65727000 Intrauterine pregnancy (finding)
713575004 Dizygotic twin pregnancy (disorder)
713576003 Monozygotic twin pregnancy (disorder)
72892002 Normal pregnancy (finding)
77386006 Pregnant (finding)
786067000 Intramural ectopic pregnancy of myometrium (disorder)
79290002 Cervical pregnancy (disorder)
79586000 Tubal pregnancy (disorder)
80997009 Quintuplet pregnancy (disorder)
82661006 Abdominal pregnancy (disorder)
83074005 Unplanned pregnancy (finding)
87527008 Term pregnancy (finding)
87605005 Cornual pregnancy (disorder)
90968009 Prolonged pregnancy (disorder)
9279009 Extra-amniotic pregnancy (finding)
9899009 Ovarian pregnancy (disorder)

This is captured by adding a procedure with a valid SNOMED code using the Procedure widget in a note or by adding a diagnosis with a valid ICD10 or SNOMED code using the Diagnosis widget in a note.

ICD-10:  
Code Description
Z51.5 Encounter for palliative care

 

SNOMED:  
Code Description
103735009 Palliative care (regime/therapy)
133918004 Comfort measures (regime/therapy)
182964004 Terminal care (regime/therapy)
305284002 Admission by palliative care physician (procedure)
305381007 Admission to palliative care department (procedure)
305981001 Referral by palliative care physician (procedure)
306237005 Referral to palliative care service (procedure)
306288008 Referral to palliative care physician (procedure)
385736008 Dying care (regime/therapy)
385763009 Hospice care (regime/therapy)
385765002 Hospice care management (procedure)

This is captured by checking the BMI not done for medical or other reason check box, using the Options button, which is located under the BMI section from the Vitals widget in a note.

 

Or, by attaching an applicable SNOMED code to a procedure.

SNOMED:  
Code Description
183932001 Procedure contraindicated (situation)
183964008 Treatment not indicated (situation)
183966005 Drug treatment not indicated (situation)
266721009 Absent response to treatment (situation)
269191009 Late effect of medical and surgical care complication (disorder)
31438003 Drug resistance (disorder)
35688006 Complication of medical care (disorder)
397745006 Medical contraindication (finding)
407563006 Treatment not tolerated (situation)
410534003 Not indicated (qualifier value)
410536001 Contraindicated (qualifier value)
416098002 Allergy to drug (finding)
428119001 Procedure not indicated (situation)
59037007 Intolerance to drug (finding)
62014003 Adverse reaction caused by drug (disorder)
79899007 Drug interaction (finding)

This is captured by checking the BMI refused by patient check box, using the Options button, which is located under the BMI section from the Vitals widget in a note.

 

Or, by attaching an applicable SNOMED code to a procedure.

SNOMED:   
Code Description
105480006 Refusal of treatment by patient (situation)
183944003 Procedure refused (situation)
183945002 Procedure refused for religious reason (situation)
413310006 Patient non-compliant – refused access to services (situation)
413311005 Patient non-compliant – refused intervention / support (situation)
413312003 Patient non-compliant – refused service (situation)

Required Data Elements for the Numerator:

This is calculated automatically when entering a height and weight using the Vitals widget in a note.

 

If the BMI is outside of the normal parameters, at least ONE of the following must be documented within the 12 months prior to or during the first BMI Encounter of the measurement period:

This is captured by checking the Follow-up plan documented check box, using the Options button, which is located under the BMI section from the Vitals widget in a note.

The reason of Overweight will be saved automatically if the most recent BMI result >= 25 kg/m2.

The reason of Underweight will be saved automatically if the most recent BMI result < 18.5 kg/m2.

Or, by adding a procedure with a valid CPT code, HCPCS code, or SNOMED code, using the Procedure widget in a note; or, by adding a valid ICD-10 code using the Diagnosis widget in a note.

Valid Codes for Above Normal BMI:

CPT/HCPCS:
Code Description
43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)
43645 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption
43659 Unlisted laparoscopy procedure, stomach
43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components)
43771 Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only
43772 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only
43773 Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only
43774 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components
43842 Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty
43843 Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty
43845 Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch)
43846 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy
43847 Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption
43848 Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure)
43886 Gastric restrictive procedure, open; revision of subcutaneous port component only
43888 Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only
97802 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes
97803 Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes
97804 Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes
98960 Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient
99078 Physician or other qualified health care professional qualified by education, training, licensure/regulation (when applicable) educational services rendered to patients in a group setting (eg, prenatal, obesity, or diabetic instructions)
99401 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes
99402 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes
G0270 Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes
G0271 Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes
G0447 Face-to-face behavioral counseling for obesity, 15 minutes
G0473 Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes
S9449 Weight management classes, non-physician provider, per session
S9451 Exercise classes, non-physician provider, per session
S9452 Nutrition classes, non-physician provider, per session
S9470 Nutritional counseling, dietitian visit

 

SNOMED:
Code Description
304549008 Giving encouragement to exercise (procedure)
307818003 Weight monitoring (regime/therapy)
361231003 Prescribed dietary intake (regime/therapy)
370847001 Dietary needs education (procedure)
386291006 Exercise promotion: strength training (procedure)
386292004 Exercise promotion: stretching (procedure)
386373004 Nutrition therapy (regime/therapy)
386463000 Prescribed activity/exercise education (procedure)
386464006 Prescribed diet education (procedure)
410177006 Special diet education (procedure)
413315001 Nutrition / feeding management (regime/therapy)
418995006 Feeding regime (regime/therapy)
424753004 Dietary management education, guidance, and counseling (procedure)
443288003 Lifestyle education regarding diet (procedure)

 

ICD-10:
Code Description
Z71.3 Dietary counseling and surveillance
Z71.82 Exercise counseling

 

Valid Codes for Below Normal BMI:

CPT/HCPCS:  
Code Description
97802 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes
97803 Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes
97804 Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes
98960 Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient
99078 Physician or other qualified health care professional qualified by education, training, licensure/regulation (when applicable) educational services rendered to patients in a group setting (eg, prenatal, obesity, or diabetic instructions)
99401 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes
99402 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes
G0270 Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes
G0271 Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes
S9449 Weight management classes, non-physician provider, per session
S9452 Nutrition classes, non-physician provider, per session
S9470 Nutritional counseling, dietitian visit

 

SNOMED:  
Code Description
386464006 Prescribed diet education (procedure)
410177006 Special diet education (procedure)
413315001 Nutrition / feeding management (regime/therapy)
418995006 Feeding regime (regime/therapy)
424753004 Dietary management education, guidance, and counseling (procedure)
429095004 Dietary education for weight gain (procedure)
443288003 Lifestyle education regarding diet (procedure)

 

ICD-10:  
Code Description
Z71.3 Dietary counseling and surveillance

This is captured by attaching a weight assessment SNOMED code when adding/editing a referral using the Referral button in a note.

referral_snomed

The reason of overweight will be saved automatically if the most recent BMI result >= 25 kg/m2.

The reason of underweight will be saved automatically if the most recent BMI result < 18.5 kg/m2.

SNOMED:   
Code Description
103698003 Patient referral to non-physician provider (procedure)
103699006 Patient referral to dietitian (procedure)
183515008 Referral to physician (procedure)
183524004 Referral to psychiatry service (procedure)
183583007 Refer to mental health worker (procedure)
185359002 Referred by another general practitioner (finding)
305922005 Referral by mental health counselor (procedure)
306136006 Referral to liaison psychiatry service (procedure)
306163007 Referral to dietetics service (procedure)
306164001 Referral to community-based dietetics service (procedure)
306165000 Referral to hospital-based dietetics service (procedure)
306166004 Referral to occupational therapy service (procedure)
306167008 Referral to community-based occupational therapy service (procedure)
306168003 Referral to hospital-based occupational therapy service (procedure)
306226009 Referral to mental health counseling service (procedure)
306227000 Referral for mental health counseling (procedure)
306252003 Referral to mental health counselor (procedure)
306344004 Referral to professional allied to medicine (procedure)
306353006 Referral to community-based dietitian (procedure)
306354000 Referral to hospital-based dietitian (procedure)
308459004 Referral to psychologist (procedure)
308470006 Referral to general physician (procedure)
308477009 Referral to psychiatrist (procedure)
390864007 Referral for exercise therapy (procedure)
390866009 Referral to mental health team (procedure)
390893007 Referral to physical activity program (procedure)
408289007 Refer to weight management program (procedure)
410160006 Physical therapy management (procedure)
416790000 Referral for home physical therapy (procedure)
424203006 Physical therapy education, guidance and counseling (procedure)
91251008 Physical therapy procedure (regime/therapy)

This is captured by prescribing or renewing a medication with a valid RXNORM code using the Medication button in a note or the Facesheet in a chart.

The reason of overweight will be saved automatically if the most recent BMI result >= 25 kg/m2.

The reason of underweight will be saved automatically if the most recent BMI result < 18.5 kg/m2.

Valid Medications for Above Normal BMI:

RXNORM:  
Code Description
1112982 Phentermine Hydrochloride 15 MG Disintegrating Oral Tablet
1112987 Phentermine Hydrochloride 30 MG Disintegrating Oral Tablet
1249083 Phentermine Hydrochloride 37.5 MG Disintegrating Oral Tablet
1302827 24 HR Phentermine 7.5 MG / topiramate 46 MG Extended Release Oral Capsule
1302839 24 HR Phentermine 3.75 MG / topiramate 23 MG Extended Release Oral Capsule
1302850 24 HR Phentermine 15 MG / topiramate 92 MG Extended Release Oral Capsule
1313059 24 HR Phentermine 11.25 MG / topiramate 69 MG Extended Release Oral Capsule
314153 orlistat 120 MG Oral Capsule
692876 orlistat 60 MG Oral Capsule
803348 Phentermine Hydrochloride 37.5 MG Oral Capsule
803353 Phentermine Hydrochloride 37.5 MG Oral Tablet
826131 Phentermine Hydrochloride 18.8 MG Oral Capsule
826919 Phentermine Hydrochloride 8 MG Oral Tablet
900038 Phentermine Hydrochloride 30 MG Oral Capsule
968766 Phentermine Hydrochloride 15 MG Oral Capsule
978654 Diethylpropion Hydrochloride 25 MG Oral Tablet
978668 24 HR Diethylpropion Hydrochloride 75 MG Extended Release Oral Tablet

Valid Medications for Below Normal BMI:

RXNORM:  
Code Description
197634 dronabinol 10 MG Oral Capsule
197635 dronabinol 2.5 MG Oral Capsule
197636 dronabinol 5 MG Oral Capsule
577154 Megestrol Acetate 125 MG/ML Oral Suspension
860215 Megestrol Acetate 20 MG Oral Tablet
860221 Megestrol Acetate 40 MG Oral Tablet
860225 Megestrol Acetate 40 MG/ML Oral Suspension

BMI Measurement Guidance:

  • Height and Weight – An eligible professional or their staff is required to measure both height and weight. Both height and weight must be measured within twelve months of the current encounter and may be obtained from separate encounters. Self-reported values cannot be used.
  • The BMI may be documented in the medical record of the provider or in outside medical records obtained by the provider.
  • If the most recent documented BMI is outside of normal parameters, then a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter.
  • If more than one BMI is reported during the measurement period, the most recent BMI will be used to determine if the performance has been met.
  • Review the exclusions and exceptions criteria to determine those patients that BMI measurement may not be appropriate or necessary.

Additional Information:

  • This eCQM is a patient-based measure. This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period.
  • There is no diagnosis associated with this measure.
  • This measure may be reported by eligible professionals who perform the quality actions described in the measure based on the services provided at the time of the qualifying visit and the measure-specific denominator coding.
  • The SNOMED codes required for Overweight, Underweight, MUST be attached to either: the procedure code indicating Follow-Up Intervention; the same procedure code where the SNOMED for Follow-up or Referral Intervention are attached (Note:  the BMI office encounter code can not be used); a procedure, other than the office encounter code, when prescribing the medication intervention.
  • When using a SNOMED code for Patient, Medical or Other reason not performed: it MUST be attached to the same procedure as the Under/Overweight SNOMED code; the procedure code must also be marked as “Procedure Not Performed”; the procedure code can not be the BMI office encounter code.
  • When using a SNOMED code for Follow-Up Intervention or Referral, it must be attached to the same procedure code as the Under/Overweight SNOMED code (Note:  the BMI office encounter code cannot be used).
  • The only data used to determine the denominator is data from the ChartMaker Clinical Module. If a patient encounter was not entered into the ChartMaker Clinical Module, that encounter is not included in the denominator for the statistical calculations on the Meaningful Use Dashboard. Please add these additional patients to the denominator and recalculate the percentage for Attestation purposes.