Wiki can i code this DX

[trinapitsch]

In the note the provider has documented this in the medical hisotory

MEDICAL HISTORY:

Past medical history includes hypertension

The plan states:

BLOOD PRESSURE OF 146/96. PATIENT HAS NOT TAKEN BLOOD PRESSURE MEDICATIONS IN THE PAST TWO DAYS. I WANTED HIM TO TAKE HIS BLOOD PRESSURE MEDS AND HAVE HIS BLOOD PRESSURE CHECKED IN THE NEXT 7-10 DAYS.

my coworkers say i cannot code the HTN but must instead code "elevated blood pressure" what is your take on this?

Thanks!

 

[BenCrocker]

Um, Elevated blood pressure by definition is Hypertension unless they changed the definition on us.

 

[trinapitsch]

um, i was told to use:

796.2 - elevated blood pressure reading with no DX of HTN, since the provider did not say in the actual plan HTN

As opposed to 401.9

 

[mitchellde]

The code for elevated BP specifically states without a DX of HTN. This patient has it in the medical history that the have HTN and they are on meds for the HTN. Code the HTN.
Ben.. A patient can have isolated elevated BP without having a dx of HTN. The standard is usually 3 elevated BP readings in row, then the provider needs to determine if this is HTN.
I might also use a code for noncompliance. For ICD-10 CM, this would be an instance of Under dosing. You would code the HTN, followed by the T code for the drug with the 6th character 6 for under dosing, and 7th character A. Then you would use the Z code for non compliance with medication.

 

[trinapitsch]

Thank you so much Debra, i truly value your expertise and knowledge on all things coding.

 

[melbad]

Hx of HTN ON MEDS

If this patient is already on hypertensive treatment they HAVE HTN. Not just a random elevated BP. Code 401.9

 

[BenCrocker]

Exactly in this case HISTORY and medication check for HTN sort of makes the Elevated Blood Pressure point moot. Code the HTN.