Wiki Another HTN question

[LTibbetts]

I have been coding a lot of labs lately and on the encounter sheets I receive are diagnosis codes that should be entered to support each test (and these are not initially picked by coders, by the way, but by computer software, and entered by whomever is registering the patient, so they are just going by what the provider has told them to enter). Sometimes I come across the 997.91, but this is only a print out of a lab order, not an encounter sheet or written order, so there is no supporting dx to explain what the complication is. I know that I can't use a "9" code without a code to explain the complication further, and they don't state whether or not the patients htn is benign or malignant, so I have been using the 401.9. Is this appropriate? Does anyone have any info regarding this type of situation? I could really use some advice. Thanks

diagnosis codes, diagnosis coding

 

[mitchellde]

I would definitely ask to see the documentation for this. The problem for me is that the code reads:
997.91 Hypertension
Excludes:
Essential hypertension (401. 0-401.9)
And when taken out of the context of its category
997 Complications affecting specified body systems, not elsewhere classified
Use additional code to identify complication
Can be read by software to be the code for hypertension.
You will notice that 997.91 excludes 401.1-401.9, this is a complication that is affecting the hypertension not causing hypertension so we need another code to specify what that complication is.
I would be willing to bet that none of these charts indicate a complication at all but are instead drug monitoring for the drugs they are taking to control the hypertension and should be V58.83 with V58.6X. But I would not do anything with out a review of the medical record. Remember it is the patient's dx and we cannot indicate that a complication exists if there is not one documented.

diagnosis codes, diagnosis coding