I11.9 is for hypertensive cardiovascular disease without heart failure. If my provider states that this is, in parentheses, "Complications due to hypertension," and the hypertension is primary, do I code both I10 and I11.9? Or is I11.9 sufficient? Whenever I11.9 is coded, is it necessary to identify the type of associated hypertension? I can't find any information on this.
This is from the guidelines. You don't need the I10, just the combination code. Hope this helps!
9. Combination Code
A combination code is a single code used to classify:
Two diagnoses, or
A diagnosis with an associated secondary process (manifestation)
A diagnosis with an associated complication
Combination codes are identified by referring to subterm entries in the
Alphabetic Index and by reading the inclusion and exclusion notes in the
Tabular List.
Assign only the combination code when that code fully identifies the
diagnostic conditions involved or when the Alphabetic Index so directs.
Multiple coding should not be used when the classification provides a
combination code that clearly identifies all of the elements documented in the
diagnosis. When the combination code lacks necessary specificity in
describing the manifestation or complication, an additional code should be
used as a secondary code
1) Hypertension with Heart Disease
Heart conditions classified to I50.- or I51.4-I51.9, are assigned
to a code from category I11, Hypertensive heart disease, when a
causal relationship is stated (due to hypertension) or implied
(hypertensive). Use an additional code from category I50, Heart
failure, to identify the type of heart failure in those patients with
heart failure.
The same heart conditions (I50.-, I51.4-I51.9) with
hypertension, but without a stated causal relationship, are coded
separately. Sequence according to the circumstances of the
admission/encounter.