Common ICD-10 OBGYN Codes

The clinical concepts for OBGYN guide includes common ICD-10 codes, clinical documentation tips and clinical scenarios.

Abnormal Female Genital Cytology

(Excluding Neoplasia and Malignancy Codes)

(ICD-9-CM 622.10, 622.11, 622.12, 792.9, 795.01 to 795.19 range, 795.4)

R87.610 Atypical squamous cells of undetermined significance on cytologic smear of cervix (ASC-US)
R87.611 Atypical squamous cells cannot exclude high grade squamous intraepithelial lesion on cytologic smear of cervix (ASC-H)
R87.612 Low grade squamous intraepithelial lesion on cytologic smear of cervix (LGSIL)
R87.613 High grade squamous intraepithelial lesion on cytologic smear of cervix (HGSIL)
R87.615 Unsatisfactory cytologic smear of cervix
R87.616 Satisfactory cervical smear but lacking transformation zone
R87.618 Other abnormal cytological findings on specimens from cervix uteri
R87.619* Unspecified abnormal cytological findings in specimens from cervix uteri
R87.620 Atypical squamous cells of undetermined significance on cytologic smear of vagina (ASC-US)
R87.621 Atypical squamous cells cannot exclude high grade squamous intraepithelial lesion on cytologic smear of vagina (ASC-H)
R87.622 Low grade squamous intraepithelial lesion on cytologic smear of vagina (LGSIL)
R87.623 High grade squamous intraepithelial lesion on cytologic smear of vagina (HGSIL)
R87.625 Unsatisfactory cytologic smear of vagina
R87.628 Other abnormal cytological findings on specimens from vagina
R87.629* Unspecified abnormal cytological findings in specimens from vagina
R87.69 Abnormal cytological findings in specimens from other female genital organs
N87.0 Mild cervical dysplasia
N87.1 Moderate cervical dysplasia
N87.9* Dysplasia of cervix uteri, unspecified
R87.810 Cervical high risk human papillomavirus (HPV) DNA test positive
R87.811 Vaginal high risk human papillomavirus (HPV) DNA test positive
R87.820 Cervical low risk human papillomavirus (HPV) DNA test positive
R87.821 Vaginal low risk human papillomavirus (HPV) DNA test positive

Excessive, Frequent and Irregular Menstruation

(ICD-9-CM 626.2 To 626.6 Range, 627.0)

N92.0 Excessive and frequent menstruation with regular cycle
N92.1 Excessive and frequent menstruation with irregular cycle
N92.2 Excessive menstruation at puberty
N92.3 Ovulation bleeding
N92.4 Excessive bleeding in the premenopausal period
N92.5 Other specified irregular menstruation
N92.6* Irregular menstruation, unspecified

General Medical and Gynecological Examinations

(ICD-9-CM V70.0, V72.31, V72.32) (Excluding Contraceptive and Procreative Codes)

Z00.00 Encounter for general adult medical exam without abnormal findings
Z00.01 Encounter for general adult medical exam with abnormal findings
Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings
Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings
Z01.42 Encounter for cervical smear to confirm findings of recent normal smear following initial abnormal smear

Hypertension

(ICD-9-CM 401.9)

I10 Essential (primary) hypertension

Inflammation of Vagina and Vulva

(ICD-9-CM 616.10, 616.4, 616.50, 616.81, 616.89)

N76.0 Acute vaginitis
N76.1 Subacute and chronic vaginitis
N76.2 Acute vulvitis
N76.3 Subacute and chronic vulvitis
N76.4 Abscess of vulva
N76.5 Ulceration of vagina
N76.6 Ulceration of vulva
N76.81 Mucositis (ulcerative) of vagina and vulva
N76.89 Other specified inflammation of vagina and vulva

Lump in Breast and Other Disorders of the Breast

(ICD-9-CM 611.2, 611.3, 611.4, 611.5, 611.6, 611.71 to 611.79 range, 611.81 To 611.89 range, 611.9)

N63* Unspecified lump in breast
N64.0 Fissure and fistula of nipple
N64.1 Fat necrosis of breast
N64.2 Atrophy of breast
N64.3 Galactorrhea not associated with childbirth
N64.4 Mastodynia
N64.51 Induration of breast
N64.52 Nipple discharge
N64.53 Retraction of nipple
N64.59 Other signs and symptoms in breast
N64.81 Ptosis of breast
N64.82 Hypoplasia of breast
N64.89 Other specified disorders of breast
N64.9* Disorder of breast, unspecified

Selected Menopausal and Other Perimenopausal Disorders

(ICD-9-CM 627.0 to 627.9 range) (Excluding Post-menopausal Osteoporosis and Urethritis Codes)

N92.4 Excessive bleeding in the premenopausal period
N95.0 Postmenopausal bleeding
N95.1 Menopausal and female climacteric states
N95.2 Postmenopausal atrophic vaginitis
N95.8 Other specified menopausal and perimenopausal disorders
N95.9* Unspecified menopausal and perimenopausal disorder

Noninflammatory Disorders of Ovary, Fallopian Tubes, and Broadligament

(ICD-9-CM 620.0 to 620.9 range)

N83.0 Follicular cyst of ovary
N83.1 Corpus luteum cyst
N83.20* Unspecified ovarian cysts
N83.29 Other ovarian cysts
N83.31 Acquired atrophy of ovary
N83.32 Acquired atrophy of fallopian tube
N83.33 Acquired atrophy of ovary and fallopian tube
N83.4 Prolapse and hernia of ovary and fallopian tube
N83.51 Torsion of ovary and ovarian pedicle
N83.52 Torsion of fallopian tube
N83.53 Torsion of ovary, ovarian pedicle and fallopian tube
N83.6 Hematosalpinx
N83.7 Hematoma of broad ligament
N83.8 Other noninflammatory disorders of ovary, fallopian tube & broad ligament
N83.9* Noninflammatory disorder of ovary, fallopian tube and broad ligament, unspecified

Supervision of Normal Pregnancy

(ICD-9-CM V22.0, V22.1, V22.2)

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

Urinary Tract Infection, Cystitis

(ICD-9-CM 599.0, 595.0, 595.1, 595.2, 595.3, 595.4, 595.5, 595.81, 595.82, 595.89)

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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
Supervision of Normal Pregnancy (ICD-9-CM V22.0, V22.1, V22.2)
*Codes with a greater degree of specificity should be considered first.
N30.00 Acute cystitis without hematuria
N30.01 Acute cystitis with hematuria
N30.10 Interstitial cystitis (chronic) without hematuria
N30.11 Interstitial cystitis (chronic) with hematuria
N30.20 Other chronic cystitis without hematuria
N30.21 Other chronic cystitis with hematuria
N30.30 Trigonitis without hematuria
N30.31 Trigonitis with hematuria
N30.40 Irradiation cystitis without hematuria
N30.41 Irradiation cystitis with hematuria
N30.80 Other cystitis without hematuria
N30.81 Other cystitis with hematuria
N30.90 Cystitis, unspecified without hematuria
N30.91 Cystitis, unspecified with hematuria
N39.0* Urinary tract infection, site not specified