Wiki can i code this DX

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trinapitsch

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In the note the provider has documented this in the medical hisotory

MEDICAL HISTORY:

Past medical history includes hypertension

The plan states:

BLOOD PRESSURE OF 146/96. PATIENT HAS NOT TAKEN BLOOD PRESSURE MEDICATIONS IN THE PAST TWO DAYS. I WANTED HIM TO TAKE HIS BLOOD PRESSURE MEDS AND HAVE HIS BLOOD PRESSURE CHECKED IN THE NEXT 7-10 DAYS.

my coworkers say i cannot code the HTN but must instead code "elevated blood pressure" what is your take on this?

Thanks!
 
um, i was told to use:

796.2 - elevated blood pressure reading with no DX of HTN, since the provider did not say in the actual plan HTN

As opposed to 401.9
 
The code for elevated BP specifically states without a DX of HTN. This patient has it in the medical history that the have HTN and they are on meds for the HTN. Code the HTN.
Ben.. A patient can have isolated elevated BP without having a dx of HTN. The standard is usually 3 elevated BP readings in row, then the provider needs to determine if this is HTN.
I might also use a code for noncompliance. For ICD-10 CM, this would be an instance of Under dosing. You would code the HTN, followed by the T code for the drug with the 6th character 6 for under dosing, and 7th character A. Then you would use the Z code for non compliance with medication.
 
Hx of HTN ON MEDS

If this patient is already on hypertensive treatment they HAVE HTN. Not just a random elevated BP. Code 401.9
 
Exactly in this case HISTORY and medication check for HTN sort of makes the Elevated Blood Pressure point moot. Code the HTN.
 
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