Home Health ICD-9/ICD-10 Alert

Watch for October changes to hypertension's fifth digit.

Problem: When coding for a patient who has hypertension, you can assume a link with some co-morbidities, but the link to others must be documented by a physician. Do you know which is which?

"There is a code for hypertensive kidney and heart disease (404.xx), but I don't know if it's appropriate to use this code when the history and physical doesn't state a relationship between his heart disease and hypertension," says Paloma Valenzuela, LVN, with Care Quality of El Paso, TX.

Link Hypertension And Kidney Disease

You can assume a cause-and-effect relationship between chronic kidney disease and hypertension, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates in Denton, TX.

Coding guidelines state that you can assign a code from the 403.xx (Hypertensive kidney disease) category when conditions classified to categories 585-587 are present. ICD-9-CM assumes a cause-and-effect relationship and classifies renal failure with hypertension as hypertensive kidney disease.

Don't miss: Changes effective Oct. 1 add the word "chronic" to the title so that 403 is titled hypertensive chronic kidney disease to further detail the code's vascular origin and the end organ involvement, Selman-Holman says. Because you cannot have hypertensive chronic kidney disease without chronic kidney disease, the 2006 fifth digits were incorrect and have been revamped for 2007, she says.

Don't Assume With Heart Disease

Coders are not allowed to assume a cause and effect relationship between cardiac problems and hypertension, Selman-Holman says. Using a code from the 402.x (Hypertensive heart disease) category indicates that the hypertension is responsible for the cardiac condition.

Physician documentation is required to demonstrate this link. You can't assume that your patient has hypertensive heart disease because he has both hypertension and a heart condition such as heart failure, Selman-Holman says.
 
Coding scenario: Your patient has chronic kidney disease (CKD) stage III, congestive heart failure (CHF), cardiomyopathy and malignant hypertension. The physician states that the kidney failure is related to the hypertension, but doesn't indicate whether the heart disease is related.

Should you report the hypertension with 403.00 (Hypertensive chronic kidney disease; malignant; with chronic kidney disease, Stage I-IV or unspecified) or can you link the CHF and report 404.01 (Hypertensive heart and chronic kidney disease; malignant; with heart failure and chronic kidney disease Stage I-IV, or unspecified)?

While you can't assume a link between hypertension and heart disease, there are some clues in this scenario that the patient does have hypertensive heart disease, Selman-Holman says. The fact that his hypertension is malignant and that he has cardiomyopathy could indicate a link, she says.

In this scenario, ask the physician whether the patient has hypertensive cardiomyopathy and hypertensive heart failure, Selman-Holman says. If the physician confirms your suspicions, then use a 404.x (Hypertensive heart and chronic kidney disease) code to indicate that the patient has both hypertensive kidney disease and hypertensive heart disease rather than reporting both a 402 and a 403 code, she says.
 
With this patient, for code 404 use the fourth digit "0" for "malignant," and the fifth digit "1" for "with heart failure and with chronic kidney disease stage I through stage IV, or unspecified," Selman-Holman says. So, your final code is 404.01

Your ICD-9 manual will instruct you to also code the type of heart failure and the stage of chronic kidney disease for this patient, Selman-Holman says. So, follow 404.01 with:

• 428.0 (Congestive heart failure, unspecified),

• 425.x (Cardiomyopathy) and

• 585.3 (Chronic kidney disease, Stage III [moderate]).

If you can't confirm hypertensive heart disease for this patient, code for the hypertension with 403.00 (Hypertensive chronic kidney disease; malignant; with chronic kidney disease, Stage I-IV or unspecified), Selman-Holman says.
 
Sequence 585.3 (Chronic kidney disease, Stage III) after the 403 code in either case, she says. The cardiac issues may be coded according to severity and do not have to follow the hypertension code if you cannot confirm the hypertensive heart disease