Transcript Coding Hypertension and Hyperlipidemia

Coding Hypertension and
Hyperlipidemia
Beth Sassano CCS-P, CPC, CPC-I, CPMA
HYPERTENSION (HTN)
 Blood pressure is a measurement of the resistance against the
artery walls as the heart pumps blood.
 Narrow, stiff, or clogged blood vessels may increase blood
pressure.
 The constant elevated resistance may lead to chronic or acute
health conditions such as heart disease or stroke.
HYPERTENSION in ICD-9
 Blood pressure can vary a day or a week. Therefore, one occurrence of an elevated blood
pressure reading is not usually diagnosed as hypertension.
 ICD-9-CM code 796.2 is assigned for elevated blood pressure without a diagnosis of
HTN and also for transient or borderline hypertension.
 Look at the hypertension table in the index.
 Once the diagnosis of HTN is established by a provider, a code from category 401 is
assigned, with a fourth digit required:
 0 for malignant,
 1 for benign, and
 9 for unspecified.
** Do not assign a code for benign or malignant HTN unless it is specifically
documented by a physician.
2 Types of HYPERTENSION
 There are two main types of hypertension: primary or essential and secondary.
 Primary hypertension has no known cause. Gradually develops over many years.
Primary hypertension is classified to category 401.
 Secondary Hypertension is caused by an underlying condition. This can
appear suddenly and causes higher blood pressure than primary hypertension.
 Common causes include specific renal diseases such as polycystic kidney disease;
adrenal gland tumors/disorders; congenital defects of blood vessels; certain
medications; renal artery stenosis; and hyperparathyroidism
 2 codes are required to code secondary HTN: One for the underlying cause and
one from category 405 to identify the hypertension.
HYPERTENSION WITH HEART DISEASE
 Hypertension with certain types of heart conditions are assigned
to a code from category 402, Hypertensive heart disease when
the provider states a causal relationship between bot
dx.’s.
 Use a from category 402 to identify both the hypertension and the
heart condition, with the exception of heart failure.
 If heart failure is present with the hypertensive heart disease, add a
code to identify the specific type of heart failure (category 428).
Heart conditions mentioned with hypertension, without a stated
causal relationship (i.e. due to or with), are coded separately. Sequence
according to the circumstances of the visit.
HYPERTENSION WITH CKD
 Assign codes from category 403, hypertensive chronic kidney
disease, when conditions classified to category 585, chronic
kidney disease and 587, renal sclerosis unspecified, are
present with hypertension.
 Unlike hypertension with heart disease, ICD-9-CM presumes
a cause-and-effect relationship and classifies chronic kidney
disease with hypertension as hypertensive chronic kidney
disease.
HYPERTENSIVE HEART AND CHRONIC
KIDNEY DISEASE
 Assign codes from combination category 404, hypertensive
heart and chronic kidney disease, when both hypertensive
chronic kidney disease and hypertensive heart conditions are
stated in the diagnosis. Assume a relationship between the
hypertension and the chronic kidney disease whether or not
the condition is so designated.
 Do not report 402.x and 403.x together
Combination Code Categories
Not all hypertensive diseases have combination codes. When a
patient is diagnosed with hypertensive retinopathy (362.11),
First assign the code from subcategory 362.11, hypertensive
retinopathy then report the correct hypertension code from
401.x-405.x to indicate the type of hypertension.
Controlled verses Non-Controlled HTN
ICD-9 does not categorize hypertension by level of control. Hypertension is
categorized as benign or malignant. If a note indicates only “uncontrolled
hypertension”, the correct coding is 401.9, “hypertension, unspecified”.
If there is hypertensive heart or kidney disease present, these should be coded in
the 402.X or 403.X range.
You should not code 401.1 unless your documentation says that the hypertension is
benign
Uncontrolled hypertension is defined as a systolic blood pressure >140 mmHG
and a diastolic blood pressure >90 mmHG. Uncontrolled refers to a person who is
not being treated for hypertension. Most people have few or no symptoms with
hypertension, however some of the symptoms include headaches, dizzy spells,
nosebleeds, and rapid heart rates.
ICD-10 HYPERTENSION
In ICD-10-CM, hypertension is no longer classified as
malignant, benign, or unspecified. There is no more “table of
hypertension” to refer to. The following are the categories
available for hypertension in ICD-10-CM:
• I10, Essential (primary) hypertension;
• I11, Hypertensive heart disease;
• I12, Hypertensive chronic kidney disease;
• I13, Hypertensive heart and chronic kidney
disease; and
• I15, Secondary hypertension.
ICD-10 HYPERTENSION
 Code I10 is used when hypertension is not specified or associated
with another disease such as chronic kidney disease.
 A condition of elevated blood pressure without a diagnosis of
hypertension is classified to code R03.0, Elevated blood pressure
reading.
 Post procedural hypertension, I97.3, is located in the category
for Intraoperative and post-procedural complications and
disorders of the circulatory system, not elsewhere classified.
ICD-10
 Hypertensive disease codes in ICD-10 exclude several conditions:
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hypertension complicating pregnancy,
neonatal hypertension,
primary pulmonary hypertension, and
primary and secondary hypertension involving vessels of the brain or
the eye.
 You will need to be careful throughout the “Diseases of the
Circulatory System” chapter 7 of ICD-10 to distinguish the
capital “I” from the number “1.”
 The hypertension codes span from I10 to I15 (there is no I14), and
each series has its own peculiarities
Documentation
 ICD-10 is implementing new documentation requirements in
order to support the specificity needed for the new codes.
 Remember documentation is about quality not quantity. You
will not have to write a lengthy visit note for each and every
patient visit, rather, you will need to provide good
documentation of why the patient was there, what was done
or performed, and the medical decision making. Also
document follow-up treatment.
Documentation
 If the patient visit is more complex, your documentation will
also have to be much more complex, containing details that
the medical coders will need in order to assign the correct
diagnosis code for ICD-10.
Example: I10, Essential (primary) HTN
As in ICD-9, this code includes “high blood pressure” but remember it does not
include elevated blood pressure without a diagnosis of hypertension (that would be
R03.0).
If a patient increased from elevated blood pressure to a diagnosis of hypertension,
include the reason for the patient progressed to a dx. of HTN.
Example:
 Your patient, a 60 year old male has had blood pressure readings between 140/80–90
for several visits. At his annual examination, you and the nurse document his blood
pressure as 140/92 .You discuss with him the importance of diet, exercise, and
reducing stress ,and schedule another appointment for next month to recheck his BP.
 At that visit, he again has a readings above 140/90, has been watching his diet and
has increased his exercising so you document the patient’s advancement from
elevated blood pressure (R03.0) to essential hypertension (I10).
Hypertension with hypertensive heart
disease: I11
 Like ICD-9, when you code hypertension with heart failure,
(I11.0) in ICD-10, you are required to add a code for the
type of heart failure from the I50 series:
 I50.1, Left ventricular failure,
 I50.2, Systolic (congestive) heart failure,
 I50.3, Diastolic (congestive) heart failure,
 I50.4, Combined systolic and diastolic heart failure,
 I50.9, Heart failure, unspecified.
Heart Failure in ICD-10
I50:
Code first:
 Heart failure complicating abortion or ectopic or molar
pregnancy – O00-O007, )08.8
 Heart Failure following surgery – I97.13x
 Heart failure due to HTN I11.0
 Heart failure due to HTN with CKD – II13. Obstetric surgery and procedures O75.4
 Rheumatic Heart failure I09.81
Hypertension with hypertensive heart
disease: I50 category CONT……
Codes for systolic, diastolic, and combined failure also require a
fifth digit specifying the acuity of the diagnosis:
 0, Unspecified,
 1, Acute,
 2, Chronic,
 3, Acute on chronic.
Heart conditions with hypertension, but without a stated casual
relationship, are coded separately. Sequence according to the reason
for the visit (Chapter 9 guidelines)
Hypertension / Chronic Kidney
Disease: I12
Like ICD-9, ICD-10 presumes a cause and effect (etiology/manifestation) relationship and
classifies the condition as hypertensive chronic kidney disease when the patient has both.
Both ICD-9 and ICD-10 require specifying the stage of the chronic kidney disease
to properly code the condition.
ICD-10 sequences I12 series first for the combined diagnosis of hypertension and chronic
kidney disease:
 I12.0, Hypertensive chronic kidney disease with stage 5 chronic kidney disease or endstage renal disease,
 Use additional code to identify the stage of chronic kidney dz (N18.5, N18.6)
 I12.9, Hypertensive chronic kidney disease with stage 1 through 4 chronic kidney
disease or unspecified chronic kidney disease.
 Use additional code to identify the stage of chronic kidney dz (N18.1-N18.4, N18.9)
Hypertension and chronic kidney
disease: I12 cont…..
I12.0 and I12.9 require an additional code of N18 to identify
the stage of kidney disease. See:
 N18.1, Chronic kidney disease, stage 1,
 N18.2, Chronic kidney disease, stage 2 (mild),
 N18.3, Chronic kidney disease, stage 3 (moderate),
 N18.4, Chronic kidney disease, stage 4 (severe),
 N18.5, Chronic kidney disease, stage 5,
 N18.6, End-stage renal disease,
 N18.9, Chronic kidney disease, unspecified.
Hypertension, Hypertensive Heart Disease,
and Chronic Kidney Disease: I13
To make things more confusing, if the patient has all three
diseases (hypertension, heart disease, and chronic kidney
disease), the provider will need to document the relationship
between the hypertension and heart disease but can assume the
causal relationship between hypertension and chronic kidney
disease.
Hypertension, Hypertensive Heart Disease, and
Chronic Kidney Disease: I13
The codes for the three-diseases together are put in order by the stage of chronic kidney
disease rather than with or without heart failure:
 I13.0: Hypertensive heart and chronic kidney disease with heart failure and with
stage 1 through 4 chronic kidney disease, or unspecified chronic kidney
disease, Inclusion notes
 I13.10: Hypertensive heart and chronic kidney disease without heart failure with
stage 1 through stage 4 chronic kidney disease, or unspecified chronic
kidney disease, Inclusion notes
 I13.11: Hypertensive heart and chronic kidney disease without heart failure with
stage 5 chronic kidney disease, or end-stage renal disease, Inclusion notes
 I13.2: Hypertensive heart and chronic kidney disease with heart failure and with
stage 5 chronic kidney disease, or end-stage renal disease. Inclusion notes
Nicotine/Tobacco use or exposure in
patients with HTN
HTN codes require an additional ICD-10 code if the patient is a
current or former user of tobacco. Usually, you will use one of
the following codes found in chapter 5:
F17: Nicotine dependence:
 F17.20x:
Unspecified,
 F17.21x:
Cigarettes,
 F17.22x:
Chewing tobacco,
 F17.29x:
Other tobacco product
Nicotine/Tobacco use or exposure in
patients with HTN
 Each of the sub-categories has a required sixth character:
 0 - uncomplicated,
 1 - in remission,
 3 - with withdrawal,
 8 - with other specified nicotine-induced disorder,
 9 - with unspecified nicotine-induced disorder.
Nicotine Dependence – Z17
Excludes 1:
Hx. Of tobacco dependence (Z87.891)
Tobacco use not otherwise specified (NOS) (Z72.0
Use Z72.0 if the patient is not documented as dependent
Excludes 2Tobacco use (smoking( during pregnancy, childbirth, and the
puerperium (O99.33-)
Add codes for occupational and environmental exposure to tobacco should if the provider
believes this is influencing the patient's health status.
The codes are as follows:
 Z57.31 - Occupational exposure to environmental tobacco smoke,
 Z72.0 - Problems related to lifestyle, tobacco use,
 Z77.22 - Exposure to environmental tobacco smoke (includes second-hand smoke
exposure and passive smoking),
 Z87.891 - Personal history of nicotine dependence.
Nicotine/Tobacco use or exposure in
patients with HTN
 Z87.891 - Is Personal history of nicotine dependence
 F17.2Current nicotine dependence
According to a Family Practice article by Kenneth D. Beckman, MD,
MBA, CPE, CPC:
“It states that a personal history code should be used if a patient's
condition no longer exists and is not being treated but has the
potential to recur and, therefore, may require continuous
monitoring. The remission code would be appropriate if a patient is
actively using a product to stop smoking. Once the patient has
stopped using such products, it is up to the provider to determine
when the patient's status would move from “in remission” to
“personal history of.””
Secondary HTN in ICD-10
As stated in ICD-9 there are cases of patients who have hypertension
secondary to other diseases (manifestation). In these cases, providers
cannot use the primary ICD-10 hypertension ICD-10 codes.
Instead, use the following ICD-10 Categories:
 I15.0, Renovascular hypertension,
 I15.1, Hypertension secondary to other renal disorders,
 I15.2, Hypertension secondary to endocrine disorders,
 I15.8, Other secondary hypertension,
 I15.9, Secondary hypertension, unspecified.
Also code the underlying condition from the documentation
Hypertension, hypertensive (accelerated) (benign)
(essential) (idiopathic) (malignant) (systemic) I10
with
heart involvement (conditions in I51.4- I51.9 due
to hypertension) - see Hypertension, heart
kidney involvement - see Hypertension, kidney
benign, intracranial G93.2
borderline R03.0
cardio renal (disease) I13.10
with heart failure I13.0
with stage 1 through stage 4 chronic kidney
disease I13.0
with stage 5 or end stage renal disease I13.2
without heart failure I13.10
with stage 1 through stage 4 chronic kidney
disease I13.10
with stage 5 or end stage renal disease I13.11
cardiovascular
disease (arteriosclerotic) (sclerotic) - see
Hypertension, heart
renal (disease) - see Hypertension, cardio renal
chronic venous - see Hypertension, venous (chronic)
complicating
childbirth (labor) O10.92
with
heart disease O10.12
with renal disease O10.32
renal disease O10.22
with heart disease O10.32
essential O10.02
secondary O10.42
pregnancy O16.with edema - see also Pre-eclampsia O14.9gestational (pregnancy induced) (transient) (
without proteinuria) O13.with proteinuria O14.9mild pre-eclampsia O14.0moderate pre-eclampsia O14.0severe pre-eclampsia O14.1with hemolysis, elevated liver enzymes and low platelet
count (HELLP) O14.2pre-existing O10.91with
heart disease O10.11with renal disease O10.31pre-eclampsia O11.renal disease O10.21with heart disease O10.31essential O10.01secondary O10.41puerperium, pre-existing O10.93
with
heart disease O10.13
with renal disease O10.33
renal disease O10.23
with heart disease O10.33
essential O10.03
pregnancy-induced O13.9
secondary O10.43
Hypertension, hypertensive (accelerated) (benign)
(essential) (idiopathic) (malignant) (systemic) I10
Due to
endocrine disorders I15.2
pheochromocytoma I15.2
renal disorders NEC I15.1
arterial I15.0
renovascular disorders I15.0
specified disease NEC I15.8
encephalopathy I67.4
gestational (without significant proteinuria) (pregnancy-induced)
O13.with significant proteinuria - see Pre-eclampsia
Goldblatt's I70.1
heart (disease) (conditions in I51.4-I51.9 due to hypertension)
heart failure (congestive) I11.0
kidney disease (chronic) - see Hypertension, c
intracranial (benign) G93.2
kidney I12.9
with
heart disease - see Hypertension, cardiorenal
stage 5 chronic kidney disease (CKD) or end stage
disease (ESRD) I12.0
stage 1 through stage 4 chronic kidney disease I12.9
lesser circulation I27.0
newborn P29.2
pulmonary (persistent) P29.3
ocular H40.05pancreatic duct - code to underlying condition
with chronic pancreatitis K86.1
portal (due to chronic liver disease) (idiopathic) K76.6
gastropathy K31.89
in (due to) schistosomiasis (bilharziasis) B65.9
(transient)
I11.9 with
ardiorenal
renal
postoperative I97.3
psychogenic F45.8
pulmonary (artery) (secondary) I27.2 with
cor pulmonale (chronic) I27.2
acute I26.09
right heart ventricular strain/failure I27.2
acute I26.09
of newborn (persistent) P29.3
primary (idiopathic) I27.0
renal - see Hypertension, kidney
renovascular I15.0
secondary NEC I15.9
due to
endocrine disorders I15.2
pheochromocytoma I15.2
renal disorders NEC I15.1
arterial I15.0
renovascular disorders I15.0
specified NEC I15.8
venous (chronic)
due to
deep vein thrombosis - see Syndrome,
postthrombotic
idiopathic I87.309
with
inflammation I87.32with ulcer I87.33specified complication NEC I87.39ulcer I87.31with inflammation I87.33asymptomatic I87.30-
Hypertension Fast Finder
Hyperlipidemia per Wikipedia
 Hyperlipidemia, hypolipoproteinemia, or hyperlipidemia
(British English) involves abnormally elevated levels of any or all lipids
and/or lipoproteins in the blood. It is the most common form of
dyslipidemia (which includes any abnormal lipid levels).
 Lipids (fat-soluble molecules) are transported in a protein capsule. The
size of that capsule, or lipoprotein, determines its density. The
lipoprotein density and type of apoliproteins it contains determines the
fate of the particle and its influence on metabolism.
 Hyperlipidemias are divided into primary and secondary subtypes.
Primary hyperlipidemia is usually due to genetic causes (such as a
mutation in a receptor protein), while secondary hyperlipidemia arises
due to other underlying causes such as diabetes. Lipid and lipoprotein
abnormalities are common in the general population, and are regarded
as a modifiable risk factor for cardiovascular disease due to their
influence on atherosclerosis. In addition, some forms may predispose to
acute pancreatitis.
Hyperlipidemia per Wikipedia
 Hyperlipidemias are also classified according to which types
of lipids are elevated, that is:
 hypercholesterolemia,
 hypertriglyceridemia or both in
 combined hyperlipidemia.
Elevated levels of lipoprotein may also be classified as a form of
hyperlipidemia.
Hyperlipidemia in ICD-9
 When ICD-10 goes into effect in 2015, high cholesterol will
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still be a challenge for your patients. Here’s a look at how
coding for this, and similar diagnoses, compares between
ICD-9 and ICD-10.
ICD-9-CM Codes:
272.0, Pure hypercholesterolemia
272.1, Pure hyperglyceridemia
272.2, Mixed hyperlipidemia
272.4, Other and unspecified hyperlipidemia
Hyperlipidemia in ICD-10
 E78.0, Pure hypercholesterolemia
 E78.1, Pure hyperglyceridemia
 E78.2, Mixed hyperlipidemia
 E78.4, Other hyperlipidemia
 E78.5, Hyperlipidemia, unspecified
Hyperlipidemia
 Change: ICD-10 offers a one-to-one code match with ICD-
9 for:
 pure hypercholesterolemia (272.0 / E78.0),
 pure hyperglyceridemia (272.1 / E78.1),
 mixed hyperlipidemia (272.2 / E78.2).
But where ICD-9 offers one code for “other and unspecified
hyperlipidemia” (272.4), ICD-10 offers one code for “other”
(E78.4) and a different code for “unspecified” (E78.5).
The End
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