Sexual abuse complicating pregnancy, unspecified trimester

This code signifies a diagnosis of sexual abuse occurring during a pregnancy, where the specific trimester is not documented. It indicates that the abuse is considered a complication impacting the pregnant patient's health and well-being. This diagnosis highlights the need for comprehensive care addressing both the physical and psychological sequelae of abuse within the context of pregnancy.

Apply this code when documentation clearly states sexual abuse as a complication of pregnancy, but the medical record does not specify the trimester in which the abuse occurred or was identified. This code is appropriate when the physician explicitly links the sexual abuse to the current pregnancy encounter. Supporting documentation would include notes from a physician, social worker, or mental health professional detailing the abuse and its impact on the pregnant patient.

• Always seek to clarify the trimester if possible; if specified, use the more precise trimester-specific codes (O9A.411, O9A.412, O9A.413).
• This code should be sequenced as a secondary diagnosis, following the code for the primary obstetric condition or reason for the encounter.
• Ensure documentation supports the "complicating pregnancy" aspect, not just a historical mention of abuse.