Primary Care Coding Alert

Once you’ve answered the quiz questions on page 35, compare your answers with the ones provided below:

Answer 1: “According the ICD-10 guidelines, ‘The classification presumes a causal relationship between hypertension and heart involvement and between hypertension and kidney involvement, as the two conditions are linked by the term “with” in the Alphabetic Index. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated,’” Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico, explains.

But don’t think that once a provider documents hypertension and either heart disease or chronic kidney disease (CKD), you should automatically reach for one of the combination codes — either I11.- (Hypertensive heart disease) or I12.- (Hypertensive chronic kidney disease) — unless the provider’s notes clearly state the conditions are unrelated.

ICD-10 guidelines I.9.a.1. and I.9.a.2. support this approach and state that “heart conditions … with hypertension are coded separately if the provider has documented they are unrelated to the hypertension,” and “CKD should not be coded as hypertensive if the provider indicates the CKD is not related to the hypertension.”

Answer 2: “The guidelines note that you should report code R03.0 [Elevated blood-pressure reading, without diagnosis of hypertension] unless the provider has documented that the patient has hypertension. Clinically, a diagnosis of hypertension is made based on serial office blood pressure recordings of at least three measurements spaced over a period of weeks to months” Witt advises. So, you would use this code to record an episode of elevated blood pressure as an isolated incidental finding or when no formal diagnosis of hypertension has been made.

Coding caution: In cases where female patients are experiencing hypertension due to pregnancy, ICD-10 guidelines direct you to code either O13.- (Gestational [pregnancy-induced] hypertension without significant proteinuria) or O14.- (Pre-eclampsia), depending on your provider’s documentation.

Answer 3: Because the kidney disease is causing the hypertension — in clinical terms, the narrowing of the arteries that carry blood to the kidneys creates a rise in blood pressure — the hypertension isn’t the “essential” or “primary” condition in this case and should not be coded first.

This means you should go to the I15.- (Secondary hypertension) codes, where a note directs you to code also the underlying condition. For example, if your practitioner examines a patient who has renal artery stenosis that is causing hypertension, you would code I70.1 (Atherosclerosis of renal artery) with I15.0 (Renovascular hypertension) as the secondary, or underlying, condition.

Pro coding tip: “Code I15.- implies a situation where resolving the other condition would resolve the hypertension. This means you should not typically switch the order of these codes, because the purpose of the renal code is to give more details about the type and degree of renal injury,” explains Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.