Health Information Compliance Alert

Question: Our new software package is pushing us to list hypertension as the primary diagnosis. I'm concerned about this because it doesn't seem accurate and I have heard there are edits in place for hypertension. Should I accept what the software suggests or am I right to be concerned?

Answer: You're right to be concerned. Overuse of hypertension codes 401.1 (Benign essential hypertension) and 401.9 (Unspecified essential hypertension) led CMS to eliminate case mix points for these diagnoses. Many agencies used these HTN case mix codes as a primary diagnosis at start of care and again in the second, third, or subsequent recertifications, which lead to edits intended to determine whether agencies were reporting these diagnoses to add case mix points or to keep the patient on services.

However, when hypertension is the primary diagnosis, if your patient's blood pressure is stable and you've already provided teaching on any new hypertension medication, it's time to work toward discharge. Continuing to keep the patient and to report hypertension as primary is bound to draw scrutiny.

Watch for changes: Remember that skilled observation and assessment means there is a reasonable potential for change. If there have been changes in dosage, medications, etc., then HTN has met criteria for skilled observation and assessment but if there has been no change or there have been changes in the condition but there has been no response to that change, then HTN does not meet the criteria.

Instead, consult the documentation to see if there is another diagnosis that supports the need for skilled services. You can still list the hypertension diagnosis in M1022 if you are continuing to monitor the patient's blood pressure, but after the first episode, it's likely the hypertension has stabilized and doesn't meet the requirements for the principal diagnosis.

Some coders were confused about the removal of 401.9 and 401.1 from the case mix diagnosis list but remember these are still valid codes. You should still list them when they are the focus of your care and as co-morbidities when hypertension has the potential to impact your care.