Normal and Cesarean Delivery ICD-10-CM codes

O80 is used only when every element is normal: a full-term pregnancy, spontaneous cephalic vaginal delivery of a single healthy liveborn infant, no antepartum, intrapartum, or postpartum complication, and no instrumentation beyond an episiotomy. O80 is always the principal diagnosis, it is never used with any other chapter 15 code, and Z37.0 (single live birth) is the only acceptable outcome code with it. A first- or second-degree perineal laceration (O70.0, O70.1), post-term pregnancy (O48.0), or any other complication means the complication is coded instead of O80.

O82 is a cesarean delivery for which no indication is documented. When the record gives a reason, code that reason rather than O82: a previous cesarean scar is O34.21- (O34.211 low transverse, O34.219 unspecified type), breech presentation is O32.1XX0, and so on. O75.82 reports spontaneous onset of labor between 37 and 39 weeks with a delivery by planned cesarean, sequenced after the indication. The principal diagnosis for a delivery admission is the condition that prompted the admission; when a cesarean is performed, it is the condition that led to the cesarean if that condition is related to the reason for admission.

Every delivery record needs a Z37 outcome of delivery code (Z37.0 single live birth, Z37.9 unspecified) and a Z3A code for weeks of gestation (Z3A.39, Z3A.40). Disruption of a cesarean wound is O90.0. Routine postpartum follow-up after discharge is Z39.2, not a delivery code.