Internal Medicine Coding Alert

Reader Question:

Choose Between Malignant and Benign

Question: Do you have any advice on how I should differentiate between benign or malignant hypertension? What should I look for in the physician documentation?

New York Subscriber

Answer: You should always follow the internist's medical documentation. Usually the physician will state in the medical record if the patient has malignant hypertension (401.0) or benign hypertension (401.1).
 
Also, you could refer to the ICD-9-CM manual, which offers definitions for both malignant and benign hypertension:
 

  •  401.0 - Malignant (Severe high arterial blood pressure; results in necrosis in kidney, retina, etc.; hemorrhages occur, and death commonly due to uremia or rupture of cerebral vessel)
     
  •  401.1 - Benign (Mildly elevated arterial blood pressure).

    If your physician doesn't clearly state "malignant" or "benign" in the documentation, you should encourage the physician to do so.

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