Appropriate Dx for Hypertension

she803

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Which dx for hypertension applies to this report and other diagnoses as well? I'm not sure if to use dx 416.0 for hypertension and 434.91 for CVA--thanks!

Examination: CT Angio Chest w&w/o contrast

History: 78-year-old woman with history of CVA. Now with hypertension and tachycardia. Unequal blood pressure in the arms. Elevated D-dimer, possible subclavian stenosis
.
Technique: Multiple contiguous 1.25 mm axial images were obtained from thoracic inlet to the midabdomen after administration of intravenous contrast material, as per departmental PE protocal.

Comparison is made with prior study from May 9, 2011

Findings:
There is no central, interlobar or segmental pulmonary embolism. The subsegmental vessels are not well visualized. There is atherosclerotic disease and thrombosis involving the proximal left subclavian artery just above the origin, although more distally to vessel is patent, unchanged from prior study. There is no thoracic lymphadenopathy. The heart is normal in size and there is no pericardial effusion. There are streaky opacities in both lower lobes which likely represents atelectasis. There is no consolidation, pleural effusion or pneumothorax.

There are multiple small nodules in the thyroid bilaterally, similar to prior study. Correlation with thyroid function tests is recommended. There is a porcelain gallbladder with a small amount of pericholecystic fluid. A gastric tube is noted. The remainder of the visualized upper abdominal organs are normal. There are degenerative changes of the thoracic spine.

Impression:
1. No pulmonary embolism
2. Atherosclerotic disease and thrombosis involving the proximal left subclavian artery, although more distally the vessel is patent
3. Multiple small nodules in the thyroid bilaterally, correlation with thyroid function tests is recommended
4. Porcelain gallbladder and a small amount of pericholecystic fluid
 
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Love Coding!

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Which dx for hypertension applies to this report and other diagnoses as well? I'm not sure if to use dx 416.0 for hypertension and 434.91 for CVA--thanks!

Examination: CT Angio Chest w&w/o contrast

History: 78-year-old woman with history of CVA. Now with hypertension and tachycardia. Unequal blood pressure in the arms. Elevated D-dimer, possible subclavian stenosis
.
Technique: Multiple contiguous 1.25 mm axial images were obtained from thoracic inlet to the midabdomen after administration of intravenous contrast material, as per departmental PE protocal.

Comparison is made with prior study from May 9, 2011

Findings:
There is no central, interlobar or segmental pulmonary embolism. The subsegmental vessels are not well visualized. There is atherosclerotic disease and thrombosis involving the proximal left subclavian artery just above the origin, although more distally to vessel is patent, unchanged from prior study. There is no thoracic lymphadenopathy. The heart is normal in size and there is no pericardial effusion. There are streaky opacities in both lower lobes which likely represents atelectasis. There is no consolidation, pleural effusion or pneumothorax.

There are multiple small nodules in the thyroid bilaterally, similar to prior study. Correlation with thyroid function tests is recommended. There is a porcelain gallbladder with a small amount of pericholecystic fluid. A gastric tube is noted. The remainder of the visualized upper abdominal organs are normal. There are degenerative changes of the thoracic spine.

Impression:
1. No pulmonary embolism
2. Atherosclerotic disease and thrombosis involving the proximal left subclavian artery, although more distally the vessel is patent
3. Multiple small nodules in the thyroid bilaterally, correlation with thyroid function tests is recommended
4. Porcelain gallbladder and a small amount of pericholecystic fluid
The physician does not state whether the hypertension is benign or malignant, or what type of hypertension the patient has. Unless you query the physician on type it should be 401.9...
 

she803

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Thanks. Also, curious to know during what accounter should I apply dx 997.91?
 

Tonyj

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Which dx for hypertension applies to this report and other diagnoses as well? I'm not sure if to use dx 416.0 for hypertension and 434.91 for CVA--thanks!

Examination: CT Angio Chest w&w/o contrast

History: 78-year-old woman with history of CVA. Now with hypertension and tachycardia. Unequal blood pressure in the arms. Elevated D-dimer, possible subclavian stenosis
.
Technique: Multiple contiguous 1.25 mm axial images were obtained from thoracic inlet to the midabdomen after administration of intravenous contrast material, as per departmental PE protocal.

Comparison is made with prior study from May 9, 2011

Findings:
There is no central, interlobar or segmental pulmonary embolism. The subsegmental vessels are not well visualized. There is atherosclerotic disease and thrombosis involving the proximal left subclavian artery just above the origin, although more distally to vessel is patent, unchanged from prior study. There is no thoracic lymphadenopathy. The heart is normal in size and there is no pericardial effusion. There are streaky opacities in both lower lobes which likely represents atelectasis. There is no consolidation, pleural effusion or pneumothorax.

There are multiple small nodules in the thyroid bilaterally, similar to prior study. Correlation with thyroid function tests is recommended. There is a porcelain gallbladder with a small amount of pericholecystic fluid. A gastric tube is noted. The remainder of the visualized upper abdominal organs are normal. There are degenerative changes of the thoracic spine.

Impression:
1. No pulmonary embolism
2. Atherosclerotic disease and thrombosis involving the proximal left subclavian artery, although more distally the vessel is patent
3. Multiple small nodules in the thyroid bilaterally, correlation with thyroid function tests is recommended
4. Porcelain gallbladder and a small amount of pericholecystic fluid
Wouldn't you only code from the impression? The impression makes no reference to hypertension.
 

mitchellde

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I agree you code from the impression, it would not be incorrect to add the hypertension but it would be a 401.9 and adds nothing to the story. I am curious as to why you were thinking 416.0 which is primary pulmonary HTN, no where in this note does it state this condition, also the 434.91 is a cerebral artery occlusion with infarction, again this not mentioned only that there is a hx of a CVA so you would use a V code hx of CVA, and the 997.91 is a code for HTN as a complication from medical or surgical care. Again no where is it mentioned that there is a complication of any kind. I am just curious regarding your selections and I hope this explains why they do not apply for this documentation.
Code from the impression.
 

she803

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I'm aware that I have to dx code the impression as well as the reason for examination. In addition, I'm dealing w/ multiple reports at once so my apologies for questioning wrong inquiries. Thank you all for your input. Appreciate it.
 
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Thanks. Also, curious to know during what accounter should I apply dx 997.91?

Hi,

997.91 can be coded only when,

•Htn complication after surgery
•Hypertension complication after surgery
•Postoperative hypertension

I hope you understand about this now..........:) And moreover you cannot code hypertension for the case which you have refered for.
 
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