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Diagnosis code help pls

  1. #1
    Default Diagnosis code help pls
    Medical Coding Books
    How would you code (elevated BP) in a patient that has already been diagnosed with benign HTN ~ '08 (401.1) here for F/U after kidney transplant 3/1/10 w/elevated BP?

    Should I just continue to use 401.1 or possibly 997.91 complications affecting other body systems NEC (HTN), (no supporting documentation for complication from the MD, just a statement w/BP elevated) or 796.2 which is to be used only if a formal dx of HTN has not been made.

    We already know the pt has HTN. I just want to document that on this particular occassion it's elevated.

  2. #2
    Columbia, MO
    You can KNOW something and still not code it. You must get the documentation of the benign HTN on this visit to code it. If it is not documented either in hiostory or exam and the only documentation you hav e is an elevated BP then you can code only that 796.2. If benign HTN is documented then you code 401.1 even if it is elevated if HTN is all that is documented you must code 401.9.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Default Diagnosis code help
    Thanks, that's what I thought just wanted to be sure.

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