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Question: A patient with longstanding hypertension is referred to a cardiologist after a chest X-ray obtained for persistent cough shows an enlarged cardiac silhouette. The cardiologist reviews the imaging, performs an examination, and documents “essential hypertension, not at goal” and “cardiomegaly” in the assessment. There are no clinical findings of heart failure, and the cardiologist does not state that the cardiomegaly is unrelated to the hypertension. Should I report a diagnosis code for each condition? Should I assign a hypertensive heart disease code?

Delaware Subscriber

Answer: For these conditions, you should report only ICD-10-CM code I11.9 (Hypertensive heart disease without heart failure).

The ICD-10-CM Official Guidelines for Coding and Reporting, Section I.C.9.a.1, direct coders to presume a causal relationship between hypertension and specified heart conditions when both are documented unless the provider states that the conditions are unrelated. The guideline also specifies that no additional code is assigned to identify cardiomegaly when hypertension and cardiomegaly are coded as hypertensive heart disease; cardiomegaly is one of the conditions specifically assigned to category I11.- (Hypertensive heart disease …) when it coexists with hypertension and the conditions are not documented as unrelated. Therefore, you should not additionally assign I10 (Essential (primary) hypertension) or I51.7 (Cardiomegaly) in this scenario.

However, if the physician explicitly documents that the cardiomegaly is unrelated to the hypertension, code the conditions separately with I10 and I51.7. Coders should not infer that they are unrelated merely because the physician did not state a causal link.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC