ICD 10 Coding Alert

Remember: You should include cause for accuracy.

There are a lot of ICD-10-CM diagnosis codes that might be appropriate for a hypotension diagnosis. Coders need to be confident in their evaluation of details in patients’ medical records to know they’ve found the appropriate details for accurate code selection.

Boost your hypotension coding with these tips.

Understand Hypotension

Low blood pressure, also known as hypotension, is a blood pressure under 90/60 millimeters of mercury, says Rebecca Sanzone, CPC, CPMA, quality assurance specialist at St. Vincent Medical Group/Accension Health and coding consultant at the American College of Cardiology.

Low blood pressure is only a problem if a person develops symptoms, which can include dizziness, fainting, or shock. In severe cases, it can be life-threatening. But low blood pressure without these serious symptoms is usually not unhealthy.

If the documentation indicates unspecified hypotension, then the correct ICD-10-CM code is I95.9 (Hypotension, unspecified), says Catherine Brink, BS, CPC, CMM, president of Healthcare Resource Management in Spring Lake, New Jersey. However, there can be underlying medical conditions causing hypotension, so the documentation should state the medical problem. If the documentation states the specific type of hypotension, then the appropriate specific ICD-10-CM code should be used. Some of these include the following:

• I95.0 (Idiopathic hypotension)
• I95.1 (Orthostatic hypotension)
• I95.2 (Hypotension due to drugs)
• I95.3 (Hypotension of hemodialysis)
• I95.81 (Postprocedural hypotension)
• I95.89 (Other hypotension). This code also includes chronic hypotension.

You should always code the correct diagnosis that is documented, Brink says. It is important to educate providers that there are more specific ICD-10-CM codes for hypotension other than the unspecified code I95.9 and that those codes should be documented as the specific diagnosis rather than “unspecified.”

It is also important to remind providers that the diagnosis made at the patient encounter should be documented to support the medical necessity of performing the service rendered, according to Brink. If the diagnosis is specific for the medical problem, the appropriate ICD-10-CM code should be coded. If the diagnosis is “nonspecific,” the appropriate diagnosis should be coded. Always code from the provider’s documentation.

Look to I95.1 for Orthostatic Hypotension

Orthostatic hypotension is a common presentation of hypotension. You may also see orthostatic hypotension written in the documentation as postural hypotension.

With orthostatic hypotension, the patient’s blood pressure drops when they go from sitting to standing. This reading is in comparison to the patient’s blood pressure while sitting.

ICD-10-CM: Report I95.1 (Orthostatic hypotension) for orthostatic hypotension, Brink says.

Documentation tip: Check the medical record carefully to make sure your cardiologist specifically documented orthostatic hypotension, along with the patient’s vitals.

Symptoms: Symptoms of orthostatic hypotension include dizziness or lightheadedness when standing, fatigue, blurred vision, confusion, and nausea.

Note Existence of Postprocedural Hypotension

Patients may experience postprocedural hypotension after they come out of anesthesia on the day of surgery or in the first days after surgery.

Causes of postprocedural hypotension include infections, fever, respiratory distress, reactions from anesthesia, and hypovolemia.

ICD-10-CM: Report I95.81 (Postprocedural hypotension) for postprocedural hypotension.