Preeclampsia Documentation Guide
Pregnancy-specific hypertensive disorder characterized by new-onset hypertension and proteinuria or end-organ dysfunction after 20 weeks gestation.
ICD-10 Codes: O14.00, O14.10, O14.20, O14.90
Common Symptoms
- Elevated blood pressure
- Proteinuria
- Headache
- Visual disturbances
- Epigastric pain
Key Documentation Elements
- Severity classification (mild vs severe features)
- Blood pressure values and trends
- Proteinuria quantification (urine protein/creatinine ratio)
- Labs (platelets, LFTs, creatinine)
- Fetal status and delivery planning
Documentation Challenges
- Classifying mild vs severe preeclampsia accurately
- Documenting blood pressure trends and proteinuria quantification
- Recording fetal surveillance and maternal lab monitoring
- Capturing delivery timing decisions and magnesium sulfate use
Billing Considerations
- Severity-specific coding (O14.0 mild, O14.1 severe)
- Trimester specification required for all obstetric codes
- Critical care time documentation for severe preeclampsia
Frequently Asked Questions
How is preeclampsia severity coded in ICD-10?
Mild preeclampsia uses O14.0x, severe features use O14.1x, HELLP syndrome uses O14.2x, and unspecified uses O14.9x. Trimester digits are appended. Scribeable identifies severity from your documented blood pressures and lab values.
How does Scribeable help with preeclampsia documentation?
Scribeable captures blood pressure trends, lab results, severity criteria, fetal surveillance, and management decisions in real time, ensuring thorough documentation for this high-acuity obstetric condition.