Cardiology Coding Alert

Remember: I95.1 does not include orthostatic hypotension due to drugs.

Hypertension, abnormally high blood pressure, often receives extra attention, with the ICD-10-CM Official Guidelines for Coding and Reporting devoting an entire section to the diagnosis. However, as you strive for accuracy in your coding, it’s also equally important to understand how to correctly report hypotension, abnormally low blood pressure.

Optimal blood pressure is considered a reading that is less than 120/80 (systolic/diastolic).

When a patient has hypertension, his blood pressure will start at a reading of 140/90 (systolic/diastolic). On the other hand, when a patient has hypotension, his blood pressure will measure lower than 90/60 (systolic/diastolic).

Read on to learn more about one of the main types of hypotension — orthostatic.

Watch Out for These Symptoms

“While hypotension (hypo – under, below, decreased) relates to a low blood pressure, orthostatic hypotension (aka postural) relates to a drop in blood pressure when patients go from sitting to standing,” says Julie Graham, BA, CPC, CCC, consultant at JG Cardiology and CT Consulting in Dallas, Texas. “This reading is in comparison to their blood pressure while sitting.”

Usually, in healthy patients, low blood pressure that doesn’t accompany symptoms is not a cause for alarm. However, if a patient with low blood pressure does present with symptoms, this may be an indication of a serious underlying condition.

The main symptom of orthostatic hypotension is the patient feeling dizzy or lightheaded when standing. Other symptoms include the following:

• Fatigue
• Blurred vision
• Confusion
• Nausea.

Rely on This Code for Orthostatic Hypotension

ICD-10 choice: Coders should not diagnose patients based solely on the physician’s documentation of low blood pressure such as 90/60, according to Graham.

“The physician must document ‘orthostatic hypotension’ along with vitals in order to use I95.1 (Orthostatic hypotension), which is indicated for both postural and orthostatic (chronic) hypotension,” Graham says.

When the physician simply documents “hypotension,” your code selection would be I95.9 (Hypotension, unspecified), according to Graham.

Note: According to an Excludes1 note in the ICD-10 code set, I95.1 does not include neurogenic orthostatic hypotension [Shy-Drager] (G90.3) or orthostatic hypotension due to drugs (I95.2).

Remember These Documentation Details

Hypotension is normally a symptom to an underlying issue commonly cardiovascular, nervous system (such as brain injury), or a blood flow issue, but there are an enormity of potential causes, says Julie-Leah J. Harding, CPC, CPMA, CEMC, CCC, CRC, RMC, PCA, CCP, SCP-ED, CDIS, AHIMA-approved ICD-10 trainer and ambassador and director of clinical compliance-cardiovascular surgery at Boston Children’s Hospital in Boston, Massachusetts.

Understanding what that underlying issue is and referencing it in the documentation is vital, according to Harding.

“The documentation needs to reflect a cause and effect linkage,” Harding says. “Realize seldom should hypotension be a primary diagnosis.”

Other important details coders should note are what clinical course was taken and if it is clear what the outcome is, Harding says.

The cardiologist should always report hypotension with specific vital signs and the clinical symptoms, adds Carol Hodge, CPC, CCC, CEMC, certified medical coder of St. Joseph’s Cardiology in Savannah, Georgia.

The physician should also document the cause for the hypotension, according to Hodge.

When coding orthostatic hypotension, the patient’s blood pressures lying down, sitting, and standing should be documented, Hodge says.

Mari Robinson, A.A.S, CPC, CRC, CCC, compliance analyst of chronic conditions at Riverside Medical Group in Newport News, Virginia, emphasizes the importance of documenting the specific type of hypotension.

“A coder must be able to determine from the provider’s note whether it is orthostatic hypotension or hypotension,” Robinson says. “If the provider does not document orthostatic, then do not code orthostatic hypotension.”

“The physician should include documentation so the coder can identify if the hypotension is idiopathic, due to a drug, orthostatic, or hypotension due to another condition,” agrees Theresa Dix, CCS-P, CPMA, CCC, ICDCT-CM, coder/auditor of East Tennessee Heart Consultants in Knoxville, Tennessee. “That way the correct code can be assigned.”

Clinical indicators for orthostatic hypotension documented in a note would also include the following, according to Robinson:

• Dizziness and syncope — classic symptoms of postural hypotension.
• The patient may not fit the “classic” definition for orthostatic hypotension per the American Academy of Neurology (AAN) guidelines for the total loss of blood pressure, but the cardiologist feels the symptoms of dizziness, weakness, fatigue, or fainting upon standing [in his/her mind] meets the diagnosis of orthostatic hypotension.

“If symptoms are documented within the [history of present illness] HPI, exam, assessment, and/or plan, and the provider chooses to provide a diagnosis of orthostatic hypotension, then the coder would code orthostatic hypotension,” Robinson says. “The support of that diagnosis is found in the note where the symptoms are documented.”

The provider would then document the necessary plan for treatment of the orthostatic hypotension, Robinson adds.

Editor’s note: See next month’s issue for more about successfully reporting hypotension.