Primary vs. Secondary Hypertension

jshaw8808

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I have a cardiology office visit case wherein the Problem List in the medical documentation states, among many other conditions, "Hypertension, hard to control secondary to left ventricular noncomliance and aortic inelasticity." However, later on, in the assessment, it is stated, "Blood pressure well controlled."

My inclination was to code secondary hypertension, e.g., I15.8 Other secondary hypertension (although I'm not sure how I would report left ventricular noncompliance or aortic inelasticity). However, another coder stated that, since the assessment indicates "blood pressure well controlled," I should simply report I10.

Is this good advice? If so, why? Is it because it's well controlled (doubt that's a good reason), or is it simply because in the assessment, the doctor chose not to characterize the hypertension as secondary?

Thanks,

Jim Shaw, CPC-A
 

thomas7331

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Secondary hypertension is hypertension that is due to or caused by another disease. When the physician is saying it is 'hard to control secondary to...' here, he or she is just stating the reason why the hypertension is hard to control, not that this is hypertension is secondary to another disease process or that those issues are the underlying cause of the hypertension. I would agree with the other coder that I10 would be correct here.
 

jshaw8808

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Thanks Thomas,

So, based on left ventricular noncompliance and aortic inelasticity not being recognized medical conditions, we assume that "secondary" in this instance does not specify secondary hypertension, right?
 

thomas7331

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Thanks Thomas,

So, based on left ventricular noncompliance and aortic inelasticity not being recognized medical conditions, we assume that "secondary" in this instance does not specify secondary hypertension, right?
Not exactly, no. Those can be considered medical conditions, and since the provider has documented them as being factors in the patient's treatment, I would try to find codes for them, although the wording the provider is using is a little unconventional and it's not really clear what is meant by 'noncompliance' in this context.

But what I'm saying is that the provider has not documented that these conditions have caused the hypertension, only that they are a factor in why the hypertension is difficult to control, i.e. difficult to treat. To code secondary hypertension (or any other 'secondary' disease) requires that it be clearly be stated as such - as hypertension caused by an underlying condition. We can't assume anything - we can only just take the provider's statement at face value. Or if in doubt, query the provider for clarification.
 
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