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.

Condition ICD-9-CM ICD-10-CM
Cushing’s syndrome 255.0 E24.0 (series)
Heart failure 428.0 I50.9
Hypertension 401.9 I10-I11.0
(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].

Assessment:

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  1. Hypertension due to Cushing’s disease (405.99 Other unspecified secondary hypertension or I15.2 Hypertension secondary to endocrine disorders in ICD-10)
  2. 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)

Kathy Philp, CPC, is practice manager with a large corporation in Edmond, Okla. A CPC® since 2004, she has 20 years of experience in medical billing, collections, reimbursement, and coding. Philp has expertise in coding for vascular, spine surgeries, pulmonary, cardiology, family practice, pediatric, sleep studies, and diagnostic imaging.

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