Preterm labor with preterm delivery, unsp trimester, fetus 1

This code signifies the onset of labor contractions leading to delivery before 37 completed weeks of gestation, when the specific trimester of the pregnancy is not documented. It indicates that the preterm delivery has occurred for the first fetus in a multiple gestation or the only fetus in a singleton pregnancy.

Use this code when a patient presents with preterm labor that results in a preterm delivery, and the medical record does not specify the trimester at which the preterm labor or delivery occurred. Documentation should clearly state "preterm labor with preterm delivery" and indicate the fetus number if applicable.

• Always strive for documentation of the specific trimester (first, second, or third) to allow for a more precise code selection (O60.12x, O60.13x).
• Ensure the medical record confirms that delivery actually occurred, as this code is for "preterm labor with preterm delivery."
• Verify the fetus number in cases of multiple gestations; this code is specifically for fetus 1.