Mild to moderate pre-eclampsia, second trimester

This code signifies the presence of pre-eclampsia, a pregnancy-specific hypertensive disorder, characterized by new-onset hypertension and proteinuria, or hypertension with end-organ dysfunction, occurring during the second trimester. The "mild to moderate" designation indicates the severity of the condition, falling between gestational hypertension and severe pre-eclampsia.

Apply this code when documentation clearly states a diagnosis of mild to moderate pre-eclampsia, with the onset or diagnosis occurring specifically within the second trimester of pregnancy. Supporting documentation should include blood pressure readings, proteinuria levels (if applicable), and the gestational age at diagnosis.

• Ensure the documentation specifies "mild to moderate" severity; do not use for severe pre-eclampsia or gestational hypertension.
• Verify the trimester of onset; this code is specific to the second trimester.
• Always sequence this code as a principal diagnosis when it is the reason for the encounter, or as a secondary diagnosis when it is a co-morbidity affecting care.