Internal Medicine Coding Alert

When a patient who has not been diagnosed with hypertension has an elevated blood pressure reading, don't use a code from the 401-405 series, because that can unfairly label the patient with a hypertension diagnosis.

If the patient has not had high readings previously but exhibits a blood pressure above the normal range during an office visit check, "I would call that 'elevated blood pressure' (796.2, Elevated blood pressure reading without diagnosis of hypertension)," says Greg Pennock, MD, a cardiologist at the Heart Center of Southern Arizona in Tucson.

This is the type of patient who may be referred for ambulatory blood pressure monitoring (ABPM), says Sherry Straub, RHIT, CCS, CCS-P, coding and compliance manager at Esse Health, a multispecialty practice in St. Louis.

And you should not use the 401-405 codes for a pregnant patient with hypertension. Instead, you should use the 642 series (Hypertension complicating pregnancy, childbirth and the puerperium) in those cases.