Home Health ICD-9/ICD-10 Alert

Published on Tue Jul 17, 2012 PDF

Your key: Look for the link before listing 402.x.

When a patient has both hypertension and heart disease, knowing whether the HTN caused the heart condition is crucial to proper coding. Making this key distinction can have a positive impact on your agency's reimbursement.

If the physician says the heart failure is due to HTN, or calls the condition hypertensive heart disease or hypertensive heart failure, look to the 402.x (Hypertensive heart disease) codes, says Sharon Molinari, RN, HCS-D, HCS-O, a home health consultant based in Henderson, Nev.

When using a 402.x code, you are reflecting that the hypertension is causing the heart disease. That is why physician documentation or confirmation is required before using a 402.x code, adds Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, HCS-O, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas.

Also include the appropriate 428.x code if the patient has heart failure. Remember, you can assign more than one 428.x code if more than one applies.

Not related: If there is no documented causal relationship between the HTN and heart disease, then you should code the HTN and heart disease diagnoses separately (and should not use a 402.x code).

Coding example: Your patient has benign hypertensive heart disease with left ventricular failure.

You report 402.11 (Hypertensive heart disease; benign; with heart failure). This code indicates the patient's entire hypertensive status. Also report a code to specify the type of heart failure. In this case, 428.1 (Left heart failure). In this scenario the 402.x code (the cause) must precede the heart failure code.

Tip: When you see the word "with" in a code title, your coding manual's Alphabetic Index, or an instructional note in the Tabular List, it means "associated with" or "due to," according to the ICD-9-CM Coding Conventions.

Coding example: Your patient has benign hypertension and left ventricular failure.

In this case there is no stated or implied relationship between the hypertension and the heart failure, so you should code for them separately with 401.1 (Benign essential hypertension) and 428.1(Left ventricular failure), Selman-Holman says. There is no particular sequencing rule that applies in this scenario. The two conditions do not have to be coded together and you should sequence them according to seriousness of the condition.

Remember that heart disease and hypertension are on the same line item on the case mix variable table as seen on page 67-68 of this issue. That means that even though both the hypertension code and the heart disease code are case mix, you will only earn the points once. There were some changes in the number of points earned for these diagnoses effective January 1, and two hypertension codes -- 401.9 (Essential hypertension unspecified) and 401.1 (Essential hypertension, benign) -- are no longer case mix.

Vital: Even though the 401.9 and 401.1 codes are no longer case mix, they still may be appropriate codes to use, Selman-Holman says. Don't change your hypertension code just because it no longer earns case mix points. Always apply coding guidelines to choose the correct code for the condition documented. And remember that even though the hypertension diagnosis may not earn you any points, the diagnosis code for your patient's heart condition, in this case 428.1, will likely still provide those same points.

ICD-10-CM Note: The hypertension codes do not have specific characters for benign, malignant and unspecified in ICD-10-CM. The terms benign, malignant and unspecified are non-essential modifiers under I10-I13 hypertension codes.