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Hypertension no longer on meds

dkhclement

dkhclement

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La Place, LA
If a patient has previously been diagnosed with HTN and has been off meds for a couple of years, would the HTN still be considered a chronic condition and coded? I cannot seem to find a guideline for this, but I thought once you had the dx of HTN that you always had it. What do you think? Thanks.
 
hypertension

my question is, if in patient HPI it mention histoty of hypertension but in medical history it is not mentioned about hypertension and lab reports shows 140/100. In this condition can we give 401.9 or shall i choose 796.2,please share your idea.
 
If the Pt has been Dx with HTN, it stays as a condition, even if patient does not take Rx for it. HPI = History of present illness, that means you do not necessarily need to put it in medical Hx if it's already in the HPI. Sometimes Doctors can be redundant, but that's where you as a Coder come in.

401.9 is your answer unless the documentation specifies benign, Malignant, or related conditions.

I hope this helps,

Chaim Zeitz, CPC
 
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