Wiki History of HTN

[dda1970]

I have a patient who has a history of hypertension - they are no longer on meds and they do not have an elevated BP reading. The only code I can find for this is V12.59. Does anyone know of a more specific code or is this the best option?

 

[devinmajor14]

We were always told to still code for HTN even without the use of medication. HTN can be controlled through lifestyle changes.

 

[mitchellde]

If the HTN has in fact abated entirely then it would be incorrect to code it as an active condition. Use the hx of the V12.59or just code as a V67 for followup. It is possible the HTN was a secondary condition and was not coded properlyfrom the beginning.

 

[abhishekrane32@yahoo.com]

I will also use HTN code since HTN is chronic condition and can be controlled without medication by lifestyle changes.

 

[mitchellde]

I will also use HTN code since HTN is chronic condition and can be controlled without medication by lifestyle changes.

If that were true for this patient then the provider would not have documented the condition as history of HTN. It is not up to the coder to decide the patient's diagnosis, it is up to us to code based on the documentation provided. It is possible for HTN to no longer be a condition for a particular patient. If the provider decides the condition is history it is wrong for the coder to decide it is still an ongoing chronic condition!

 

[devinmajor14]

This will be something you may need to query the provider for more information. Just because the patient no longer needs medications nor had a high bp reading at the time of admission does not mean the patient is not controlling it through diets, ect. I see many cases where the patient no longer want medications and control it through lifestyle changes. The history code for HTN is a fairly new code. For me to code this as a history, I would need the provider to state not only the patient is no longer on medications, but also no longer having to control their bp. I would code HTN for medical necessity.

 

[mitchellde]

It is not the coders place to diagnose the patient. If the provider clearly documents the condition as being history of then that is how we code it, or as you suggest we can query the provider. However when you query the provider you must be careful to not question his medical judgement of the patient condition. Do not try to read into the documentation, you get only what the provider is stating.

 

[devinmajor14]

Well our Dr's will place a dx under history section of the chart when its not an issue time of admission. The coders will look at their medications, ect to see if the patient is still currently being treated. Our auditor says to always code HTN as current condition for medical necessity unless the provider says it's no longer being treated through medications or diets.