2025 ICD-10-CM code O16.2
(Active) Effective Date: N/A Revision Date: N/A Hypertensive disorders - Unspecified maternal hypertension Pregnancy, childbirth and the puerperium (O00-O9A) Feed
Unspecified maternal hypertension during the second trimester of pregnancy.
Appropriate coding requires documentation supporting the diagnosis of hypertension and the gestational age.The medical necessity is established by the clinical presentation and need for management of hypertension during pregnancy to prevent maternal and fetal complications.
Obstetrician/Gynecologist, primary care physician
- Pregnancy, childbirth and the puerperium (O00-O9A)
- O10-O16 (Edema, proteinuria and hypertensive disorders in pregnancy, childbirth and the puerperium)
In simple words: This code is for high blood pressure in a pregnant woman during her second trimester (weeks 14-27 of pregnancy).It's used when doctors don't know the exact type of high blood pressure.
This code classifies unspecified maternal hypertension that occurs during the second trimester of pregnancy, defined as gestational weeks 14 to 27 + 6 days.It is used when the specific type of hypertension is unknown or cannot be specified.This code should only be applied to maternal records, not those of the newborn.
Example 1: A 30-year-old pregnant woman at 20 weeks gestation presents with elevated blood pressure readings on two separate occasions.The physician performs a complete physical examination, including assessment of edema and proteinuria.No specific type of hypertension is diagnosed. Code O16.2 is assigned., A 25-year-old pregnant woman, 18 weeks pregnant, is found to have consistently high blood pressure during her routine prenatal visits. There is no evidence of proteinuria or edema. Further investigation fails to reveal any underlying cause of hypertension.Code O16.2 is assigned. , A 35-year-old woman, at 25 weeks gestation, is admitted to the hospital with complaints of severe headache and blurred vision. Blood pressure is significantly elevated.Despite investigations, no specific diagnosis of hypertension is established. Code O16.2 is assigned.Additional codes may be necessary based on the symptoms and complications.
* Detailed history and physical examination, including blood pressure readings on at least two occasions.* Documentation of gestational age.* Results of laboratory tests (e.g., urinalysis for protein, complete blood count).* Any additional investigations performed (e.g., echocardiogram).* Documentation of the absence or presence ofedema or proteinuria.
** This code is for use only on maternal records.It is important to correctly identify the trimester to ensure appropriate coding.If there is any additional information available that specifies the type of hypertension, a more specific code should be used.
- Payment Status: Active
- Specialties:Obstetrics and Gynecology
- Place of Service:Office, Hospital, Birthing Center