Home Health ICD-9/ICD-10 Alert

Question: The cardiologist documented the patient's hypertension as "uncontrolled." Does that mean that I should use a malignant hypertension ICD-9 code? What if the doctor simply states "hypertension" or "history of hypertension"?

Answer: "Uncontrolled" and "malignant" are not the same thing. Hypertension that is uncontrolled is not necessarily malignant.

Try this: The type of hypertension is what drives your hypertension code selection, not the term "uncontrolled." Uncontrolled hypertension may be coded with the fourth digit of "1" for benign or"'9" if not specified as malignant or benign. So you would use 401.9 (Essential hypertension; unspecified) instead.

Keep in mind: Hypertension, commonly referred to as "high blood pressure" or "HTN," is a medical condition in which the blood pressure is chronically elevated. Malignant hypertension is a complication of hypertension characterized by very elevated blood pressure, and organ damage in the eyes, brain, lung and/or kidneys. It includes a sustained diastolic pressure of 120 or above, despite treatment.

For you to use a malignant hypertension diagnosis, the cardiologist has to specifically say that in his documentation. Unfortunately, physicians will use words that mean one thing in ICD-9 but something else to them. When the cardiologist is vague about the type of hypertension, you should ask him what he means, have him clarify it in the medical record, and then assign the ICD-9 code accordingly.