Ob-Gyn Coding Alert

Your ob-gyn needs to start documenting the pre-eclampsia severity.

Pre-eclampsia is a condition where hypertension occurs during a patient’s pregnancy along with significant amounts of protein in the urine. This is the most common dangerous pregnancy complication, and it may affect both the mother and the unborn child.

Currently, you should report this condition with these ICD-9-CM codes:

• 642.40, Mild or unspecified pre-eclampsia as to episode of care
• 642.41, Mild or unspecified pre-eclampsia with delivery
• 642.42, Mild or unspecified pre-eclampsia with delivery with postpartum complication
• 642.43, Mild or unspecified pre-eclampsia antepartum
• 642.44, Mild or unspecified pre-eclampsia postpartum

ICD-10 Change: When your diagnosis system changes as of October 1, 2014, you should have these diagnoses on hand:

• O14.00, Mild to moderate pre-eclampsia, unspecified trimester
• O14.02, Mild to moderate pre-eclampsia, second trimester
• O14.03, Mild to moderate pre-eclampsia, third trimester
• O14.90, Unspecified pre-eclampsia, unspecified trimester
• O14.92, Unspecified pre-eclampsia, second trimester
• O14.93, Unspecified pre-eclampsia, third trimester

Right now, you would report mild pre-eclampsia with four codes (624.41-624.44), but in ICD-10-CM, you will have three diagnoses based on the patient’s trimester (O14.00-O14.03). The first code (O14.00) has an unspecified trimester, but the other two describe the second and third trimesters.

Documentation: Your provider will most likely already document the patient’s trimester, but he or she should specify the pre-eclampsia as mild and not severe pre-eclampsia or HELLP syndrome.

Here’s how you can find these codes in the Alphabetic Index:

Delivery (childbirth) (labor)

- cesarean (for)

- - pre-eclampsia O14.9-

- - - mild O14.0-

- - - moderate O14.0-

- complicating

- - pregnancy O16-

- - - gestational (pregnancy induced) (transient) (without proteinuria) O13-

- - - - with proteinuria O14.9-

- - - - - mild pre-eclampsia O14.0-

- - - - - moderate pre-eclampsia O14.0-

Pre-eclampsia O14.9-

- mild O14.0-

- moderate O14.0-

Coder tips: If your provider does not specify the severity of the pre-eclampsia, you can report O14.92-O14.93 (Unspecified pre-eclampsia ...) based on trimester.

Under the O14 category (Pre-eclampsia), you will see an Excludes1 note that forbids you from reporting these codes with pre-existing hypertension with pre-eclampsia (O11).