Wiki CKD with PMH of HTN

[jenyb]

I have an ED chart with a patient with end stage renal disease coming in for admit for dialysis. In the ED note, it states past medical history of hypertension. MD's final diagnosis is end stage renal disease on dialysis: N18.6, Z99.2. Should I be also be picking up code I12.0? I know what the guidelines say, but I'm still not sure if I should be coding the hypertension since the MD didn't address the hypertension but is listed under PMH. I'm guessing yes but would like some input on this.

 

[natashalage]

hello, I am not an expert but I agree with your rational- I would not include i10 because: it's in a past history(we don't code from the PMH), MD didn't assess, monitor i10, didn't review meds for it etc.

 

[thomas7331]

Practices I’ve worked in the past with would have coders assume that a chronic condition listed in past medical history still exists if the record shows that the patient is still taking medications for the hypertension or it is otherwise being currently treated. But if it’s only listed as history, we would not make the assumption.

In a case like this I would probably query the provider since hypertension doesn’t usually resolve, and is so often a complicating factor in renal failure. It would be best to get clarification from the provider if you can, so you can be reporting the patient’s conditions as accurately as possible.