What are the ICD‑10‑CM (International Classification of Diseases, Tenth Revision, Clinical Modification) codes for a spontaneous (unassisted) vaginal delivery and the newborn outcome?

ICD-10-CM Codes for Spontaneous Vaginal Delivery

For a spontaneous vaginal delivery, use ICD-10-CM code O80 for the maternal encounter and Z38.00 for the newborn.

Maternal Delivery Codes

Primary Delivery Code

• O80 - Encounter for full-term uncomplicated delivery 1, 2
  • This code is used for spontaneous (unassisted) vaginal delivery at term without complications
  • Requires documentation that the delivery was spontaneous, cephalic, vaginal, and full-term with a single liveborn infant 2

Additional Maternal Codes to Consider

• O80 should be accompanied by outcome of delivery code Z37.0 (Single live birth) 2
• If gestational age documentation is available, add Z3A.__ codes (weeks of gestation) - these became much more commonly available in the ICD-10 era (86.8% of deliveries vs 23.5% in ICD-9) 2
• For mode of delivery documentation, the code O80 specifically indicates spontaneous vaginal delivery, distinguishing it from operative vaginal delivery (forceps or vacuum) which would use different codes 1, 3

Newborn Codes

Primary Newborn Code

• Z38.00 - Single liveborn infant, delivered vaginally 2
  • This code is used for the newborn's birth encounter
  • Documents that the infant was born via vaginal route (not cesarean section)

Additional Newborn Considerations

• Birth weight should be documented using appropriate codes from the P07 series if applicable 1
• Gestational age at birth should be coded using P07.2_ or P07.3_ series if preterm or postterm 1

Important Coding Distinctions

What O80 Does NOT Include

• Operative vaginal delivery (forceps or vacuum-assisted) requires different codes 3
• Cesarean delivery uses O82 series codes 4
• Complicated deliveries require additional codes from O60-O77 series 2
• Preterm deliveries (<37 weeks) should not use O80 2

Common Pitfalls to Avoid

• Do not use O80 if the delivery required instrumentation (forceps or vacuum) - these are operative vaginal deliveries with distinct codes 3
• Do not use O80 for cesarean sections, even if labor was spontaneous initially 4
• Always include the outcome of delivery code (Z37.0 for single live birth) in addition to O80 2
• Document gestational age with Z3A codes when available, as this information is now captured in 86.8% of ICD-10 coded deliveries 2

Coding Algorithm

1. Confirm delivery characteristics: Spontaneous onset, vaginal route, cephalic presentation, term gestation (≥37 weeks), single infant, uncomplicated 2
2. Assign maternal code O80 for the delivery encounter 2
3. Add outcome code Z37.0 for single live birth 2
4. Add gestational age code Z3A.__ if documented 2
5. Assign newborn code Z38.00 for the infant's birth record 2
6. Add any additional codes for maternal or neonatal conditions that do not contradict the "uncomplicated" designation 2