ICD-10 Logo
ICDxICD-10 Medical Coding
ICD-10 Logo
ICDxICD-10 Medical Coding
ICD 10 CodesDiagnoses
ICD 10 CodesDiagnoses
ICD-10 Logo
ICDxICD-10 Medical Coding

Comprehensive ICD-10-CM code reference with AI-powered search capabilities.

© 2025 ICD Code Compass. All rights reserved.

Browse

  • All Chapters
  • All Categories
  • Diagnoses

Tools

  • AI Code Search
ICD-10-CM codes are maintained by the CDC and CMS. This tool is for reference purposes only.
v1.0.0
ICD-10 Guide
ICD-10 CodesChapter 15: Pregnancy, childbirth and the puerperiumO16

O16

Billable

Unspecified maternal hypertension

Chapter 15:Pregnancy, childbirth and the puerperium

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/08/2025

Code Description

ICD-10 O16 is a billable code used to indicate a diagnosis of unspecified maternal hypertension.

Key Diagnostic Point:

Unspecified maternal hypertension refers to elevated blood pressure during pregnancy that does not meet the criteria for more specific hypertensive disorders such as gestational hypertension or preeclampsia. This condition can arise at any point during pregnancy, labor, or the postpartum period. It is crucial to monitor maternal blood pressure closely, as uncontrolled hypertension can lead to serious complications for both the mother and fetus, including placental abruption, fetal growth restriction, and increased risk of cesarean delivery. Diagnostic workup typically includes regular blood pressure measurements, urinalysis to check for proteinuria, and assessment of any symptoms such as headaches or visual disturbances. Management may involve lifestyle modifications, medication, and careful monitoring to ensure the health and safety of both mother and child.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in blood pressure readings and definitions of hypertension.
  • Need for thorough documentation of maternal history and symptoms.
  • Differentiation from other hypertensive disorders in pregnancy.
  • Potential for evolving conditions requiring updated coding.

Audit Risk Factors

  • Inadequate documentation of blood pressure readings.
  • Failure to note associated symptoms or complications.
  • Misclassification of hypertension type.
  • Lack of follow-up documentation for ongoing management.

Specialty Focus

Medical Specialties

Obstetrics and Gynecology

Documentation Requirements

Detailed records of blood pressure measurements, maternal symptoms, and treatment plans.

Common Clinical Scenarios

Routine prenatal visits where hypertension is identified, management of hypertensive crises during labor.

Billing Considerations

Ensure accurate coding by documenting the timeline of hypertension onset and any interventions.

Maternal-Fetal Medicine

Documentation Requirements

Comprehensive assessments of maternal and fetal health, including ultrasound findings and fetal monitoring.

Common Clinical Scenarios

Management of high-risk pregnancies with pre-existing hypertension or developing hypertension during pregnancy.

Billing Considerations

Focus on the implications of hypertension on fetal development and the need for multidisciplinary care.

Coding Guidelines

Inclusion Criteria

Use O16 When
  • Follow the official ICD
  • CM coding guidelines for obstetric conditions, ensuring that the diagnosis is supported by clinical documentation
  • Use additional codes to specify any complications or associated conditions

Exclusion Criteria

Do NOT use O16 When
No specific exclusions found.

Related CPT Codes

99213CPT Code

Established patient office visit, Level 3

Clinical Scenario

Used for routine follow-up visits for patients with hypertension during pregnancy.

Documentation Requirements

Document blood pressure readings, symptoms, and treatment plans.

Specialty Considerations

Obstetricians should ensure that all relevant pregnancy-related factors are included.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of maternal hypertension, improving the ability to track and manage these conditions effectively. However, it has also increased the complexity of coding due to the need for precise documentation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of maternal hypertension, improving the ability to track and manage these conditions effectively. However, it has also increased the complexity of coding due to the need for precise documentation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of maternal hypertension, improving the ability to track and manage these conditions effectively. However, it has also increased the complexity of coding due to the need for precise documentation.

Resources

Clinical References

  • •
    American College of Obstetricians and Gynecologists (ACOG)

Coding & Billing References

  • •
    American College of Obstetricians and Gynecologists (ACOG)

Frequently Asked Questions

What should I document to support the use of O16?

Document all blood pressure readings, any symptoms experienced by the patient, and the management plan. Include details about the patient's medical history and any follow-up care provided.