Home Health ICD-9/ICD-10 Alert

Question: Our new patient is an 80 year-old gentleman referred to home health following hospitalization for multiple cardiac issues including, acute on chronic systolic and diastolic heart failure, hypertension, hypertensive heart disease, and chronic kidney disease, stage II. How should we code for him?

Oregon Subscriber

Answer: Code for this patient as follows, says Andrea Manning, BS, RN, HCS-D, COS-C, of Manning Healthcare Group in Talkeetna, AK.:

M1020a: 404.91 (Hypertensive heart and chronic kidney disease; with heart failure and with chronic kidney disease stage 1 through stage IV, or unspecified);

M1022: 428.43 (Combined systolic and diastolic heart failure; acute on chronic); and

M1022: 585.2 (Chronic kidney disease, Stage II [mild]).

When assigning codes for a patient with hypertension, heart failure and chronic kidney disease, it is important to determine the relationship between each of the diagnoses and then refer to the hypertension table for guidance, Manning advises.

Under ICD-9 guidelines, you can assume the relationship between the hypertension and the CKD (hypertensive CKD), Manning says. When coding for hypertensive CKD, you would use a 403.xx (Hypertensive chronic kidney disease) code.

However, because this patient has both hypertensive heart disease and hypertensive CKD, you should use a 404.xx combination code, Manning says.

Fourth digit: Base your fourth digit selection for 404.xx on whether the HTN is malignant, benign or unspecified. In this case, the physician did not state malignant or benign, so the fourth digit will be "9," or unspecified, Manning says. (See the table below.)

Fifth digit: Choose your 404.xx fifth digit based on whether or not the patient also has heart failure and the stage of the CKD, Manning says. In this case, the patient has heart failure and Stage II CKD so you would list fifth digit "1." (See the table below.)

Next, assign the appropriate 428.xx code to identify the specific type of heart failure, Manning says. In this case, the patient has both systolic and diastolic heart failure (combined) 428.4x. The physician states it as "acute on chronic," so 428.43 is your code, Manning says.

Finally, assign the appropriate code to indicate the stage of the CKD, in this case, 585.2, Manning says.

Remember the connection between hypertension and chronic kidney disease may be assumed, but the connection between hypertension and heart disease has to be documented by the physician, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, HCS-O, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, TX.

Examples of documentation that indicates a link include: "heart failure due to hypertension," "hypertensive heart failure," "hypertensive heart disease," "hypertensive cardiomegaly."

Bottom line: Just because the patient has heart failure and hypertension does not mean that you can list a 402.xx code for hypertensive heart disease or the combination code 404.xx.