Take the Guesswork Out of Hypertension Coding
- By Stacy Chaplain
- In Coding
- February 1, 2021
- 8 Comments
Paint an accurate picture of illness severity by knowing which clinical details influence code selection for hypertension and common comorbid conditions.
Hypertension is the medical term for elevated blood pressure — a serious medical condition in which the pressure of the circulating blood against the arterial walls is high enough that it may eventually cause health problems such as hypertensive heart disease and stroke. Hypertension (HTN) is a worldwide epidemic, affecting an estimated 1.13 billion people globally and nearly half of all adults in the United States. That’s roughly 108 million Americans, and only about one in four have their blood pressure under control.
Coding for hypertension requires attention to detail and a solid understanding of the ICD-10-CM Official Guidelines for Coding and Reporting. One concept integral to proper coding of high blood pressure is guideline I.A.15, which states that the words “with” and “in” in ICD-10-CM should be interpreted to mean “associated with” and “due to” when either appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. A causal relationship between the two conditions is presumed when they are linked by these terms in the code book.
Let’s practice applying this concept to arrive at the correct codes for reporting different clinical scenarios involving patients with HTN.
Coding High Blood Pressure
ICD-10-CM classifies HTN by type as essential or primary (categories I10–I13) and secondary (category I15). Report code I10 Essential (primary) hypertension for individuals who meet the criteria for hypertension and do not have any comorbid cardiac or renal disease. This code includes “high blood pressure” but is not meant to be used when elevated blood pressure is noted in an individual that has not been diagnosed with HTN. Report cases of transient HTN with R03.0 Elevated blood-pressure reading, without diagnosis of hypertension.
If HTN progresses to the point where it’s affecting a body system, combination codes come into play. Specifically, the code set addresses Hypertensive heart disease with category I11, Hypertensive chronic kidney disease with category I12, and Hypertensive heart and chronic kidney disease with category I13.
When assigning diagnosis codes for HTN, there is a presumptive cause-and-effect relationship between HTN and heart involvement and between HTN and kidney involvement, as the two conditions are linked by “with” in the Alphabetic Index. ICD-10-CM Guideline I.C.9.a instructs that even in the absence of provider documentation explicitly linking them, these conditions should be coded as related unless the documentation clearly states the conditions are unrelated.
Coding Hypertensive Heart Disease
Hypertensive heart disease can cause serious health problems and is the No. 1 cause of death associated with HTN. It refers to heart conditions caused by elevated blood pressure. The heart working under increased pressure causes a variety of cardiac disorders including heart failure, coronary artery disease, and thickening of the heart muscle (hypertrophy of the myocardium).
A code from category I11 Hypertensive heart disease is assigned when an individual has hypertensive heart disease — HTN with cardiac condition(s), classified to I50.- or I51.4–I51.9. Since ICD-10-CM presumes a causal relationship between HTN and cardiac involvement, a combination code is used to reflect that they’re related even if there is no provider documentation linking them.
Category I11 is subdivided to indicate whether heart failure is present:
I11.0 Hypertensive heart disease with heart failure
I11.9 Hypertensive heart disease without heart failure
When a patient has heart failure and HTN, code first I11.0 as instructed by the note at category I50 Heart failure. An additional code from category I50 is required to specify the type of heart failure, if known. In cases where the type of heart failure is not identified, report I50.9 Heart failure, unspecified. The codes for systolic, diastolic, and combined heart failure also require a fifth digit to specify the acuity of the diagnosis:
0 – Unspecified
1 – Acute
2 – Chronic
3 – Acute on chronic
If the provider specifically documents a different cause for the heart condition unrelated to high blood pressure, then the HTN and heart condition should be coded separately and not linked via a combination code. In such cases, sequence according to the circumstances of the admission/encounter.
Example: A patient is discharged with a diagnosis of exacerbated chronic diastolic congestive heart failure and a secondary diagnosis of hypertension. Codes reported:
I11.0 Hypertensive heart disease with heart failure
I50.32 Chronic diastolic (congestive) heart failure
Coding Hypertensive Chronic Kidney Disease
When the diagnostic statement includes both HTN and a condition classifiable to category N18 Chronic kidney disease, ICD-10-CM presumes a causal relationship and categorizes the condition as hypertensive chronic kidney disease (CKD). Use a code from category I12 to describe these two related disorders, even in the absence of documentation linking them. A fourth character is used with category I12 to indicate the stage of CKD.
Sequence first the I12 code for the combined diagnosis of HTN with CKD:
I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease
I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
These two codes also require that you report a secondary code from category N18 to identify the stage of kidney disease, with documentation typically referencing the most recent estimated glomerular filtration rate (eGFR) — the best test to measure the level of kidney function and determine the stage of renal disease.
In cases where the documentation clearly states the CKD is not related to the HTN, the conditions should be coded separately. The guidelines further specify that if a patient has hypertensive chronic kidney disease and acute renal failure, an additional code for acute renal failure is required.
Example: A provider documents HTN and stage IIIb kidney disease based on the patient’s most recent comprehensive metabolic profile, which showed elevated blood urea nitrogen (BUN) and creatinine and an eGFR at 40 (mL/min/1.73m2). Repeat testing yields a similar result. Codes reported:
I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
N18.32 Chronic kidney disease, stage 3b
Coding Hypertensive Heart and CKD
If a patient has all three conditions documented — HTN, heart disease, and CKD — look to combination category I13 for code assignment. Codes for the three-disease combination are numerically arranged by the degree of CKD and then further differentiated by the presence or absence of heart failure.
I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
I13.10 Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease
I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease
As with the two-disease combination codes, all of the three-disease combination codes require additional coding from category N18 to identify the stage of kidney disease. The three-combination codes that include heart failure also require an additional code from the I50 series to specify the type and acuity of the failure.
Example: The patient in the example above presents with new-onset moderate pedal edema, and, upon examination, the provider detects mild crackles bilaterally at the lung bases. An echocardiogram is ordered, which shows mild systolic heart failure. Her eGFR has remained stable. The provider documents all three conditions. Codes reported:
I13.0 Hypertensive heart and chronic kidney disease with heart failure and with stage 1 through 4 chronic kidney disease, or unspecified chronic kidney disease
I50.21 Acute systolic (congestive) heart failure
N18.32 Chronic kidney disease, stage 3b
Coding for Secondary HTN
Some patients have high blood pressure caused by another medical condition such as those that affect the kidneys, arteries, heart, or endocrine system. In these cases, the ICD-10-CM HTN codes discussed above cannot be used. Instead, turn to the codes in category I15 Secondary hypertension. The five secondary hypertension codes require that you also code the underlying condition. The first-listed code is determined based on the reason for the patient encounter.
Example: A patient is being seen for blood pressure management. The provider documents acromegaly — a hormonal disorder that develops when the pituitary gland produces too much growth hormone during adulthood — with secondary hypertension. Codes reported:
I15.2 Hypertension secondary to endocrine disorders
E22.0 Acromegaly and pituitary gigantism
Don’t Forget to Code Tobacco Use or Exposure
All of the HTN codes require an additional ICD-10-CM code, such as F17 Nicotine dependence, if the patient is a current or former tobacco user. If there is no documentation that a patient who uses tobacco is “dependent,” then you would instead use the code for tobacco use (Z72.0). Occupational and environmental exposure to tobacco should also be reported if the provider believes these are influencing the patient’s health status. Codes include:
Z57.31 Occupational exposure to environmental tobacco smoke
Z77.22 Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)
Z87.891 Personal history of nicotine dependence
Code With Confidence
Diagnosis coding for hypertensive disorders may seem convoluted at first, as there are several categories of codes. But don’t stress; there are a limited number of codes for HTN — only nine codes for primary hypertension and five codes for secondary hypertension. So, there’s no reason to let determining proper code selection for HTN raise your blood pressure. All you have to do is take a deep breath and remember to look to, and follow, the ICD-10-CM coding guidelines.
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Chronic Kidney Disease Stage 3 – N18.3 was effective through 9/30/2020.
Effective 10/1/2020 are:
N18.30 – CKD Stage 3 unspecified
N18.31 – CKD Stage 3a
N18.32 – CKD Stage 3b
Great info! Thank you! ..shouldn’t CKD, Stage 3 be N18.30?
Thanks, Candy! I’m glad you found the article helpful!! As Diane pointed out, a fifth character is needed for maximum specificity. You would not use the unspecified code N18.30 because in the first example, you are given the patient’s eGFR – 40 mL/min/1.73m2, which falls under the classification CKD Stage 3b. Thus, N18.32 would be the appropriate code to report.
Quick Question. Is HBP always coded as HTN? Does the provider need to document HTN? What if the only documentation is HBP and no mention of HTN? What is the documentation criteria for R03.0?
Hi Kristina,
No, HBP is NOT always coded as HTN. Blood pressure can vary during the day. Therefore, one elevated blood pressure reading cannot be diagnosed as hypertension. Assign code R03.0 to report an episode of elevated blood pressure in a patient in whom no formal diagnosis of hypertension has been made, or as an isolated incidental finding. R03.0 may also be used for transient hypertension – episodes of high blood pressure that are not persistent.
Once the provider makes a formal diagnosis of HTN, I10 may be reported for individuals who meet criteria for hypertension and do not have comorbid heart or kidney disease. From a documentation standpoint, it is important that the provider clearly document the basis for a newly established diagnosis of HTN. It is recommended that the provider document elevated systolic pressure above 140 or diastolic pressure above 90 with at least two readings during different office visits.
Hello,
Please provide official coding guidelines and/or coding clinic and/or guidance from aha coding handbook regarding coders being able to interpret the eGFR score into a diagnosis of CKD 3a or CKD 3b. In accordance with official coding guidelines, AHA coding handbook, and coding clinics, coders are not allowed to interpret lab results into a diagnosis. The eGFR score would be a clinical indicator of a stage of CKD however, clinicians that are legally allowed to diagnose patients’ are the only ones that can interpret the lab results into a diagnosis. I find no guidance stating otherwise. Lab results are not provider documentation. They must be interrupted by a physician. This is no different than for example of a patient with documented obesity having a BMI level of over 40- coders are not allowed to automatically code morbid obesity without physician documentation of morbid obesity. You could query in this case as well. Please someone provide and official guidance citing that coders are allowed to interpret the eGFR score into CKD 3 stage A or B?
Please reference:
Coding Clinic, Fourth Quarter ICD-10 2020 Page: 35-Code assignment should be based on provider documentation of the stage.
Coding Clinic First Quarter ICD-10 2017 Pages: 6-7, First Quarter 2000 Page: 6-
Hello,
The article does not suggest that coders interpret lab results into a diagnosis. It states that when the diagnostic statement includes both HTN and a condition classifiable to category N18, ICD-10-CM presumes a causal relationship.The appropriate code from category N18 should be used as a secondary code with a code from category I12 to identify the stage of chronic kidney disease. Documentation needs to identify the stage – stage 1-5 or ESRD – which is based off of eGFR, in order to report an additional code from category N18.
Is there any difference in reimbursement when grouping the diagnosis together as opposed to leaving them separate? I understand it is more accurate and appropriate to list the codes together, however, being technically correct may not be enough to convince some providers to change their process.