Effective Hypertension Documentation Is in the Detail
By Kathy Philp, CPC
Medical records documentation tells the relevant story of a patient in a way that even a provider who has never met the patient can understand. That level of detail may sound like a lot of work, but if the provider documents well on the initial visit, documenting subsequent visits is easier. Teaching providers how to be more specific in their reporting is more important now than ever, due to the coming implementation of ICD-10-CM.
To assist in training providers, let’s start with a frequently used diagnosis in practices: 401.9 Hypertension. In the ICD-9-CM codebook, there is a full page of potential hypertension codes from which to choose. ICD-10 offers even more code choices.
Within ICD-9-CM, there are five hypertensive categories that identify type:
401 Essential hypertension
402 Hypertensive heart disease
403 Hypertensive chronic renal disease
404 Hypertensive heart and chronic renal disease
405 Secondary hypertension
In ICD-10, the essential, benign, and malignant hypertensive codes are combined, as below:
I10 Essential (primary) hypertension — includes high blood pressure; hypertension (HTN) benign, malignant, and essential
I11 Hypertensive heart disease
I12 Hypertensive chronic kidney disease
I13 Hypertensive heart and chronic kidney disease
Documentation might be similar to the following for a patient with HTN:
- Chief complaint (CC): “Follow up for HTN.”
- Assessment: “HTN; doing well on current meds.” And the assessment may review each illness (HTN, heart failure, Cushing’s) separately.
- History: “The patient has heart failure and Cushing’s disease.”
Coders and providers may look at each diagnosis separately, coding the below scenario without realizing there may be a more appropriate code to report the highest specificity.
|Cushing’s syndrome||255.0||E24.0 (series)|
(use additional code)
Review the documentation with the provider, and ask if the patient has hypertension due to either Cushing’s syndrome and/or heart failure. If the answer is “yes” to one or both, the provider should document more explicitly (instead of separately documenting HTN, Cushing’s disease, and heart failure in the HPI). For example:
The patient has HTN due to Cushing’s disease [this could be one statement in the history].
- Hypertension due to Cushing’s disease (405.99 Other unspecified secondary hypertension or I15.2 Hypertension secondary to endocrine disorders in ICD-10)
- Hypertension with heart failure (402.91 Unspecified hypertensive heart disease with heart failure or I11.0 Hypertensive heart disease with heart failure (use additional code) in ICD-10)