Uterine size-date discrepancy, second trimester

This code signifies a notable difference between the actual size of the uterus and the expected size based on the gestational age (date of the last menstrual period or early ultrasound) during the second trimester of pregnancy. This discrepancy can indicate either a uterus that is larger or smaller than anticipated for the stage of pregnancy.

Use this code when the clinical assessment (e.g., fundal height measurement, physical examination) reveals a uterine size that deviates significantly from the expected size for the gestational age between 14 weeks 0 days and 27 weeks 6 days. Documentation should clearly state the uterine size-date discrepancy and the trimester in which it was identified.

• Ensure documentation specifies "second trimester" to differentiate from first or third trimester discrepancies.
• Do not use this code if the discrepancy is resolved or explained by a more specific diagnosis (e.g., polyhydramnios, oligohydramnios, multiple gestation).
• Consider sequencing this code after the primary reason for the encounter if the discrepancy is an incidental finding or a contributing factor to another condition.