Hypertension Coding

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Olive Branch, MS
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I am having a hard time understanding when to properly code for Hypertension. I can see coding Hypertension if it was part of the treatment, but in my case it is part of the Past Medical History. Can someone take a look at this Op Note and tell me what they would do in this case? So I can have some better clerification on the matter.


PATIENT:
DOB:
SURGEON:
ADMISSION DIAGNOSES:
Cervical spondylosis, cervical radicular pain, neck pain, upper extremity pain, and myofascial pain and spasm.

POSTOPERATIVE DISCHARGE DIAGNOSES:
Cervical spondylosis, cervical radicular pain, neck pain, upper extremity pain, and myofascial pain and spasm.

PROCEDURE:
Left C5 selective nerve root injection with fluoroscopy.

HISTORY:
Patient presents with the complaint of neck pain with radiation to the left shoulder. He has had prior surgery and prior blocks. He is currently under the expert care of Dr. Lovell who consults for today's injection.

He is advised of the potential benefits, risks, and alternatives as well as complications possible. These can include but are not limited to death, paralysis, spinal cord injury, nerve damage, bleeding, infection, allergic reactions to medications, headache, or loss of control of bladder, bowel, or sexual function. He does wish to proceed.

REVIEW OF SYSTEMS:
Positive for the above.

ALLERGIES:
Dilaudid.

MEDICATIONS:
Exforge, cabergoline, Synthroid, Plaquenil, vitamins, and fish oil.

PAST MEDICAL HISTORY:
Hypertension, hypothyroidism, and pituitary adenoma.

PAST SURGICAL HISTORY:
Lumbar discectomy on two occasions, pituitary adenoma excision, anterior cervical discectomy and fusion, thyroidectomy, and prior blocks.

PATIENT:

FAMILY HISTORY:
Noncontributory.

SOCIAL HISTORY:
Negative for alcohol or tobacco use.

PHYSICAL EXAM:
Reveals a pleasant, 59-year-old, white male, well developed, well nourished, and in some discomfort but in no acute distress. Alert and oriented times three. Height is 6', weight 235, temperature 97.5, blood pressure 169/111, pulse 70, and respirations 16. Head: Nontender. No palpable masses. Cranial nerves grossly intact. Neck: Reduced range of motion with pain that radiates to the left shoulder. Lungs: Clear to auscultation and percussion. Heart: Regular rate and rhythm. Abdomen: Soft, nontender. Bowel sounds are present. Genitourinary is deferred. Extremities: Neck pain with radiation to the left. Strength is symmetric. Deep tendon reflexes are trace. Pulses are intact. Sensation is grossly intact to soft touch.

PROCEDURE:
The patient is taken to the block room, given IV sedation, and monitored. Sterile prep and drape is applied. Local is with 3 cc of 1% plain lidocaine. Using fluoroscopic guidance, a 25-gauge needle is advanced to the neural foramen on the left at the C4-C5 level. This neural foramen was quite narrow, however, the needle was positioned without eliciting a paresthesia and confirmed with three views of image and the injection of contrast. Negative aspiration is then followed with the injection of a test dose lidocaine. This resulted in reduction of pain from a 7 to a 4. There is no evidence of intrathecal block or intravascular injection. The needle was then again negatively aspirated for cerebrospinal fluid or blood and injected with 4 mg of Decadron and 0.5 cc of 1% plain ropivacaine.

The needle is removed intact. There is no blood loss. There are no apparent complications. The patient is without complaints. He is taken to Recovery in good condition. He is asked to maintain a pain log. He will follow with me in four weeks or as needed. He will follow with Dr. Lovell as scheduled.



I AUTHORIZE MY NAME TO BE ELECTRONICALLY AFFIXED TO THIS REPORT SIGNIFYING THAT I HAVE REVIEWED AND APPROVED THE DICTATED REPORT.
 

mitchellde

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Columbia, MO
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The past medical history is not a component of the reason for this surgery nor was it identified in the note as a factor of concern. So you have no need to code the past medical history.
 
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83
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Quezon City, MM
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Chronic Condition

Hypertension is a chronic condition like diabetes, C.A.D., Autoimmune disease, etc... and coders should code this kind of condition if documented even if it's in the P.M.H., Hypertension can affect the patient health condition even if the treatment done is unrelated to HTN, it gives specificity in your coding documentation.

Patient also has Exforge an Anti-Hypertensive drug so coding HTN is important because the patient has continuous treatment for this condition.
 

mitchellde

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Columbia, MO
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The pain is here specifically for a nerve root injection for the dx of the cervical spondylosis with neck pain. The hypertension was not treated or managed at this encounter and is bot a co-morbid condition for this dx or procedure. I would recommend that it not be coded. You will not be coding an E&M either.
 

mitchellde

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Columbia, MO
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For an E&M yes but not for a procedure, when the encounter is for that procedure. You do not include the chronic underlying dx codes as part of the medical necessity for the procedure. If the patient were in the OR for an appendectomy you would not also code the hypertension. You code only the medical necessity for the procedure. The documentation for the past history could have been a cut and paste from a previous encounter.
 
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83
Location
Quezon City, MM
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why not?

coders should code condition that are present and not only the procedure for proper coding documentation, you can see that on PE the patient's Blood Pressure is 169/111. Coders needs to code all of the condition that can affect the patient health and well-being especially if there's a current treatment like medications.
 

mitchellde

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You are to code only the dx that are managed controlled or treated ant the encounter. Just because the BP is documented does not make the hypertension a condition that was addressed. The coder does not code all chronic conditions mentioned, they code only the conditions that are addressed at that encounter. The hypertension was not addressed, was not treated, was not being managed at this encounter. It was mentioned only in a history statement. This encounter was stated as being for the procedure for the diagnosis stated as the reason for the procedure. You have no service to link the hypertension with, and that also shows that it was not addressed. It it had been addressed by the provider in the examination then there would be a separate E&M to link to the hypertension. It should not be coded for this encounter since was not addressed and is not a medical necessity for the procedure.
 

RFoster1

Guru
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Houston Local Chapter
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Hx of hypertension

E&M visit

Impression:
1. C7 fracture
2. C6-C7 epidural hematoma
3. History of CLL with leukocytosis
4. History of hypertension which is controlled with medication

This is a trauma patient. We are not managing the hypertension but the physician includes it in his impression. My question is, do you use Z86.79 or I10?

Another scenario:
Sometimes physician documents "history of hypertension" but does not state whether or not it is stable or controlled. Do I code the hypertension or history of?

TIA
Ronna
 
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