2025 ICD-10-CM code O16
(Active) Effective Date: N/A Revision Date: N/A Pregnancy, childbirth and the puerperium - Edema, proteinuria and hypertensive disorders in pregnancy, childbirth and the puerperium 15 Pregnancy, childbirth and the puerperium Feed
Unspecified maternal hypertension during pregnancy, childbirth, or the puerperium.
No modifiers are applicable to ICD-10-CM codes.
Medical necessity for O16 is established by the presence of sustained elevated blood pressure during pregnancy, childbirth, or the puerperium that cannot be classified into a more specific hypertensive disorder. The need for ongoing monitoring, treatment, and management should be documented.
Obstetricians, family physicians, maternal-fetal medicine specialists, and other healthcare professionals involved in prenatal, childbirth, and postpartum care are responsible for diagnosing and managing maternal hypertension.This includes monitoring blood pressure, assessing for related complications, and providing appropriate treatment and referrals.
In simple words: This code indicates high blood pressure related to pregnancy or childbirth, without specifying the exact type.
This code signifies a form of high blood pressure that is specifically related to pregnancy, childbirth, or the postpartum period (puerperium), but is not further specified. It is used when the type of hypertension is not documented or unknown, encompassing various conditions where sustained elevated blood pressure arises in the context of pregnancy without further clarification.
Example 1: A pregnant woman in her second trimester presents with elevated blood pressure readings, but no protein in her urine and no other symptoms. The type of hypertension cannot be definitively determined, and she is diagnosed with unspecified maternal hypertension (O16.2)., A woman develops high blood pressure shortly after delivery without pre-eclampsia. Due to the unclear nature, O16.5 (Unspecified maternal hypertension, complicating the puerperium) is used., A woman in labor exhibits consistently elevated blood pressure but does not meet the criteria for pre-eclampsia or other specified hypertensive disorders. Code O16.4 is assigned to represent unspecified maternal hypertension complicating childbirth.
Documentation should include blood pressure readings, dates and times of measurements, any associated symptoms (headaches, vision changes, etc.), presence or absence of proteinuria, and other relevant clinical findings.Details regarding the onset and duration of hypertension should also be noted.
** This code is used only on the maternal record, never on the newborn's record.Accurate and detailed documentation is critical for appropriate code assignment and subsequent patient care. Consult iFrameAI for the most accurate and up to date guidelines.
- Payment Status: Active
- Specialties:Obstetrics/Gynecology, Family Medicine, Maternal-Fetal Medicine, Internal Medicine
- Place of Service:Inpatient Hospital, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital, Office, Birthing Center