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criteria for assigning a dx of HTN

  1. #1
    Exclamation criteria for assigning a dx of HTN
    Medical Coding Books
    I already know what the coding guidelines for HTN vs elevated blood pressure reading are.

    My question has to do with criteria for the physician assigning adx of HTN. In a seminar that I went to, it was stated that a patient has to have at least 3 seperately identifiable elevated blood pressure readings in order to document HTN. Has any one else heard this? I know that certain insurance companies specifically watch for this.

    Thanks!

  2. #2
    Smile
    It's true that after three positive consecutive readings of high blood presure, HTN is diagnosed, but it is ultimately the job of the physican to confirm it and not us. If only high blood pressure is mentioned w/o any sign of confirmation in HPI, PMI or anywhere else in medical record, we must not code HTN. If the patient has a history of HTN and final dx states only HBP, we can code HTN.

    HTH.
    Girish Dadhich, CPC

  3. #3
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    Quote Originally Posted by dadhich.girish View Post
    It's true that after three positive consecutive readings of high blood presure, HTN is diagnosed, but it is ultimately the job of the physican to confirm it and not us. If only high blood pressure is mentioned w/o any sign of confirmation in HPI, PMI or anywhere else in medical record, we must not code HTN. If the patient has a history of HTN and final dx states only HBP, we can code HTN.

    HTH.
    We code based on the physician documentation. If he states HTN then we code 401.9. If he states HBP then we code for that. Even if the patient history states HTN we cannot code it unless documented on the current encounter. So while it is a standard that you need
    3 elevated readings in a row, we do not question the providers ability to diagnose a condition

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
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    Quote Originally Posted by mitchellde View Post
    We code based on the physician documentation. If he states HTN then we code 401.9. If he states HBP then we code for that. Even if the patient history states HTN we cannot code it unless documented on the current encounter. So while it is a standard that you need
    3 elevated readings in a row, we do not question the providers ability to diagnose a condition
    Totally agreed. This is what I said.
    Girish Dadhich, CPC

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