'Department of Health and Human services, Victoria, Australia'

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Publication Date: June 2020

Implementation Date: 1/07/2020

ICD 10 AM Edition: Eleventh Edition

Query Number: 3584

A patient is admitted for termination of pregnancy at 6 weeks. Patient goes to theatre and suction D&C performed under IV sedation. Patient has ongoing pain and haemorrhage post operatively and ultrasound performed. Patient found to have retained clot and returned to theatre where aspiration of uterus performed.

Is the abortion coded to O04.9 or O04.1. If coded to O04.1 then would the prefix be 'C' as there was no complication on admission. Also there was no complication on admission, the complication of haemorrhage arose after the suction D&C. No documentation that the haemorrhage was a complication of the procedure apart from the procedure being incomplete with retained products and haemorrhage.


VICC advises that for the scenario cited, the correct principal diagnosis code (and only code) to assign is O04.4 Medical abortion, incomplete, without complication. This is because the documentation states that the procedure was incomplete with retained products and haemorrhage, therefore there is a documented link between the haemorrhage and the retained products.

If the haemorrhage had not been linked to retained products, the correct principal diagnosis would have been O04.1 Medical abortion, incomplete, complicated by delayed or excessive haemorrhage.

The Prefix must be P Primary condition as per ACS 0048 Condition onset flag Guide for use point 7. Where multiple conditions/sites are classifiable to a single ICD-10-AM code that meets the criteria for different condition onset flag values, assign COF 1 (see Example 12). The exception to this is when the condition is sequenced as the principal diagnosis and must be assigned COF 2 (see Example 15).