Primary Care Coding Alert

Check out the brief refresher on combination codes.

As a primary care coder, you’ve probably coded at least a few cases of hypertension. It can be a tricky condition to code though, because of its complexity and potential relationship to other diseases. The key to accurate coding is understanding the condition, the combination codes, and the documentation required.

We’ve compiled five frequently asked questions to help you brush up on your hypertension coding. How many can you answer?

Can I code for hypertension based on the numbers alone, or do I need to wait for an official diagnosis from the provider?

Answer: Even though it can be tempting to code for it prematurely, since the numbers are so familiar (even to non-healthcare workers), you should always wait for an official diagnosis.

Providers often diagnose hypertension if, when blood pressure is measured on two different days, the systolic blood pressure readings on both days is ≥140 mmHg and/or the diastolic blood pressure readings on both days is ≥90 mmHg, according to Rebecca Sanzone, CPC, CPMA, quality assurance specialist at St. Vincent Medical Group/Accension Health and coding consultant at the American College of Cardiology.

Even though the physician will strongly consider those numbers while making a diagnosis, the physician also considers the patient’s medical history, physical exam findings, and other diagnostic information. And sometimes, the patient can temporarily experience high blood pressure due to a variety of other factors.

Therefore, it’s crucial to wait for an official diagnosis rather than interpreting the clinical significance of the numbers on the patient’s record.

Is there a way to code for temporary hypertension?

Yes, but again, don’t report it unless the provider clearly documents it, and if the patient doesn’t already have an established hypertension diagnosis. If the physician confirms the diagnosis, report transient hypertension with R03.0 (Elevated blood-pressure reading, without diagnosis of hypertension).

Note: If the patient has transient hypertension of pregnancy, look to O13.- (Gestational (pregnancy-induced) hypertension without significant proteinuria) or O14.- (Pre-eclampsia) instead of R03.0.

How do you code for a postpartum follow-up visit for a patient who had gestational hypertension or preeclampsia whose symptoms are no longer present?

Answer: For a follow-up visit for gestational hypertension and preeclampsia that is no longer present at the time of the visit, report codes Z39.2 (Encounter for routine postpartum follow-up) and Z87.59 (Personal history of other complications of pregnancy, childbirth and the puerperium). This is because ICD-10-CM guidelines state that once a condition is no longer present, it is coded as a history of the problem instead.

If a patient has hypertension with both heart and kidney involvement, how do I report it?

Answer: “In order for the coder to be able to collect the details needed for selecting the correct codes for hypertension, the provider must document if the patient has congestive heart failure and/or kidney disease,” says Carol Hodge, CPC, CPMA, CDEO, CCC, CEMC, CPB, CFPC, COBGC, senior documentation specialist at St. Joseph’s/Candler Medical Group. “If so, then then the provider needs to document the type of heart failure and/or the stage of kidney disease. These are considered causal unless the provider documents that it is not causal.”

Assuming your provider has provided adequate documentation, if the patient has hypertension with both heart and kidney involvement, you’ll report a code from combination category I13- (Hypertensive heart and chronic kidney disease), per the guidelines.

Category II3- is a combination category for hypertensive heart and chronic kidney disease (CKD). When you report a code from category I13-, you must also report the appropriate secondary code from category N18- (Chronic kidney disease (CKD)) to identify the CKD stage, per the guidelines. If a patient has all three conditions (hypertension, heart disease, and CKD), then report the appropriate code from category I13-: Choose from the following:

• I13.0 (Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease)
• I13.10 (Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease). Note: This code also includes hypertensive heart disease and hypertensive chronic kidney disease NOS.
• I13.11 (Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease)
• I13.2 (Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease)

Remember: In cases like this, do not report individual codes for hypertension, heart disease, and CKD, or codes from categories I11- (Hypertensive heart disease) or I12- (Hypertensive chronic kidney disease).

Documentation alert: In each case, you will need to use an additional code to identify the stage of chronic kidney disease. If your physician documents that the patient also has heart failure, such as with I13.0 and I13.2, report the appropriate code from category I50- to identify the exact type of heart failure.