Unspecified maternal hypertension, second trimester
ICD-10 O16.2 is a billable code used to indicate a diagnosis of unspecified maternal hypertension, second trimester.
Unspecified maternal hypertension during the second trimester of pregnancy refers to elevated blood pressure readings that do not meet the criteria for specific hypertensive disorders such as gestational hypertension or preeclampsia. This condition is characterized by systolic blood pressure readings of 140 mmHg or higher and/or diastolic readings of 90 mmHg or higher, occurring after 20 weeks of gestation. The diagnosis of unspecified maternal hypertension indicates that while hypertension is present, the specific etiology or classification has not been determined. It is crucial for healthcare providers to monitor the mother closely, as uncontrolled hypertension can lead to complications such as placental abruption, fetal growth restriction, and increased risk of cesarean delivery. Diagnostic workup may include regular blood pressure monitoring, urinalysis for proteinuria, and assessment of fetal well-being through ultrasound and non-stress tests. Management typically involves lifestyle modifications, medication management, and regular follow-up to ensure both maternal and fetal health.
Detailed documentation of blood pressure readings, patient history, and management plans is essential. Providers should note any symptoms such as headaches or visual changes.
A patient presents with elevated blood pressure during a routine prenatal visit, requiring further evaluation and monitoring.
Coders should ensure that all relevant clinical findings are documented to support the diagnosis of unspecified maternal hypertension.
High-risk pregnancy documentation must include comprehensive assessments of maternal and fetal health, including ultrasound findings and laboratory results.
A high-risk patient with a history of hypertension is monitored closely for signs of progression to preeclampsia.
Special attention should be given to the management of medications and the frequency of monitoring in high-risk cases.
Used for routine follow-up visits for patients with unspecified maternal hypertension.
Documentation must include blood pressure readings, assessment of symptoms, and management plan.
Obstetricians should ensure that all relevant clinical findings are documented to support the visit level.
To support the diagnosis of unspecified maternal hypertension, document consistent blood pressure readings, any symptoms experienced by the patient, and the management plan, including lifestyle modifications or medications prescribed.
