Coding Hypertension and Hyperlipidemia

Beth Sassano CCS-P, CPC, CPC-I, CPMACoding Hypertension and HyperlipidemiaHYPERTENSION (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-9Blood 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 HYPERTENSIONThere 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 DISEASEHypertension 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 CKDAssign 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 DISEASEAssign 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 togetherCombination Code CategoriesNot 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 HTNICD-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 HYPERTENSIONIn 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 HYPERTENSIONCode 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-10Hypertensive disease codes in ICD-10 exclude several conditions: 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

DocumentationICD-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.DocumentationIf 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) HTNAs 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 140/8090 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 patients advancement from elevated blood pressure (R03.0) to essential hypertension (I10).

Hypertension with hypertensive heart disease: I11Like 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-10I50:Code first:Heart failure complicating abortion or ectopic or molar pregnancy O00-O007, )08.8Heart Failure following surgery I97.13xHeart failure due to HTN I11.0Heart failure due to HTN with CKD II13.-Obstetric surgery and procedures O75.4Rheumatic Heart failure I09.81Hypertension with hypertensive heart disease: I50 category CONTCodes 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: I12Like 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 end-stage 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: I13To 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: I13The 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 HTNHTN 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 HTNEach 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 Z17Excludes 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 HTNZ87.891 - Is Personal history of nicotine dependenceF17.2- Current 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-10As 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) I10withheart involvement (conditions in I51.4- I51.9 due to hypertension) - see Hypertension, heartkidney involvement - see Hypertension, kidneybenign, intracranial G93.2borderline R03.0cardio renal (disease) I13.10with heart failure I13.0with stage 1 through stage 4 chronic kidney disease I13.0with stage 5 or end stage renal disease I13.2without heart failure I13.10with stage 1 through stage 4 chronic kidney disease I13.10with stage 5 or end stage renal disease I13.11cardiovasculardisease (arteriosclerotic) (sclerotic) - see Hypertension, heartrenal (disease) - see Hypertension, cardio renalchronic venous - see Hypertension, venous (chronic)complicatingchildbirth (labor) O10.92withheart disease O10.12with renal disease O10.32renal disease O10.22with heart disease O10.32essential O10.02secondary O10.42

pregnancy O16.-with edema - see also Pre-eclampsia O14.9-gestational (pregnancy induced) (transient) (without proteinuria) O13.-with proteinuria O14.9-mild pre-eclampsia O14.0-moderate pre-eclampsia O14.0-severe pre-eclampsia O14.1-with hemolysis, elevated liver enzymes and low platelet count (HELLP) O14.2-pre-existing O10.91-withheart disease O10.11-with renal disease O10.31-pre-eclampsia O11.-renal disease O10.21-with heart disease O10.31-essential O10.01-secondary O10.41-puerperium, pre-existing O10.93withheart disease O10.13with renal disease O10.33renal disease O10.23with heart disease O10.33essential O10.03pregnancy-induced O13.9secondary O10.43

Hypertension, hypertensive (accelerated) (benign) (essential) (idiopathic) (malignant) (systemic) I10Due toendocrine disorders I15.2pheochromocytoma I15.2renal disorders NEC I15.1arterial I15.0renovascular disorders I15.0specified disease NEC I15.8encephalopathy I67.4gestational (without significant proteinuria) (pregnancy-induced) (transient) O13.-with significant proteinuria - see Pre-eclampsiaGoldblatt's I70.1heart (disease) (conditions in I51.4-I51.9 due to hypertension) I11.9 withheart failure (congestive) I11.0kidney disease (chronic) - see Hypertension, cardiorenalintracranial (benign) G93.2kidney I12.9withheart disease - see Hypertension, cardiorenalstage 5 chronic kidney disease (CKD) or end stage renal disease (ESRD) I12.0stage 1 through stage 4 chronic kidney disease I12.9lesser circulation I27.0newborn P29.2pulmonary (persistent) P29.3ocular H40.05-pancreatic duct - code to underlying conditionwith chronic pancreatitis K86.1portal (due to chronic liver disease) (idiopathic) K76.6gastropathy K31.89in (due to) schistosomiasis (bilharziasis) B65.9

postoperative I97.3psychogenic F45.8pulmonary (artery) (secondary) I27.2 withcor pulmonale (chronic) I27.2acute I26.09right heart ventricular strain/failure I27.2acute I26.09of newborn (persistent) P29.3primary (idiopathic) I27.0renal - see Hypertension, kidneyrenovascular I15.0secondary NEC I15.9due toendocrine disorders I15.2pheochromocytoma I15.2renal disorders NEC I15.1arterial I15.0renovascular disorders I15.0specified NEC I15.8venous (chronic)due todeep vein thrombosis - see Syndrome, postthromboticidiopathic I87.309withinflammation I87.32-with ulcer I87.33-specified complication NEC I87.39-ulcer I87.31-with inflammation I87.33-asymptomatic I87.30-

Hypertension Fast Finder

Hyperlipidemia per WikipediaHyperlipidemia, 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 WikipediaHyperlipidemias 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-9When ICD-10 goes into effect in 2015, high cholesterol will still be a challenge for your patients. Heres a look at how coding for this, and similar diagnoses, compares between ICD-9 and ICD-10.ICD-9-CM Codes:272.0, Pure hypercholesterolemia272.1, Pure hyperglyceridemia272.2, Mixed hyperlipidemia272.4, Other and unspecified hyperlipidemia

Hyperlipidemia in ICD-10E78.0, Pure hypercholesterolemiaE78.1, Pure hyperglyceridemiaE78.2, Mixed hyperlipidemiaE78.4, Other hyperlipidemiaE78.5, Hyperlipidemia, unspecifiedHyperlipidemiaChange: 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 EndTHANK YOU