Wiki 401.9 vs 796.2

[snowfall]

Code 796.2 is used when hypertension is not documented as a diagnosis on the report, etc., but what if the report does list two different antihypertensive medications the patient is on, one of which was increased at the visit due to an elevated blood pressure reading? Doesn't the medication regimen and increase indicate the diagnosis of hypertension so that 401.9 can be used?

 

[mitchellde]

Code 796.2 is used when hypertension is not documented as a diagnosis on the report, etc., but what if the report does list two different antihypertensive medications the patient is on, one of which was increased at the visit due to an elevated blood pressure reading? Doesn't the medication regimen and increase indicate the diagnosis of hypertension so that 401.9 can be used?

No the coder may not assume a Dx based on abnormal readings and/or medications.

 

[snowfall]

Thank you!