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401.9
doesn’t always cut it — and improved documentation
is the key to more specific codes
Coding
for hypertension should never feel like a coin toss.
Here’s how to get it right every time.
You
need to know whether a patient’s hypertension is malignant
or benign in order to select the most definitive ICD-9 code.
Unfortunately, physicians often don’t provide adequate
documentation on hypertension — and that can make assigning
a specific code impossible.
Experts
agree that improving physician documentation is the only
way to improve your coding specificity. Follow these three
easy steps to ensure your hypertension coding makes the
grade:
1.
Improve documentation
“The real key to correct coding for hypertension lies
with physician documentation, and we need to educate our
physicians to tell us explicitly” what type of hypertension
they’re treating, says Charla Prillaman, CPC, CHCO,
director of physician compliance for Carolinas Healthcare
System in Charlotte, NC. Physicians need to state the details
of a patient’s hypertension in the medical record,
she adds.
Coding
for hypertension “really comes down to documentation,”
agrees Jaime Darling, CPC, a coder with Graybill
Medical Group in Escondido, Calif. Often physicians will
simply write “hypertension” in the diagnosis portion
of their notes, which leads a coder to nothing but 401.9
(Essential hypertension; unspecified), she says. Explain
to your physicians that adequate information for medical
purposes isn’t always adequate for coding purposes.
Action:
Ask your physicians to indicate whether a patient’s
hypertension is malignant or benign, and also to define
how any other manifestations are related to the hypertension,
Darling recommends. For example, the physician should not
just document hypertension and renal disease, but should
indicate if the patient’s hypertension is causing renal
disease or if the renal disease is causing hypertension.
2.
Determine malignant or benign
The
hypertension table in the ICD-9-CM manual’s Index lists
three possible categories into which hypertension may fall:
Malignant, benign and unspecified. The fourth digit of the
hypertension code you report will differ depending on which
category you choose. For instance, you’ll report 401.0
for malignant essential hypertension, 401.1 for benign essential
hypertension and 401.9 for unspecified.
Malignant
hypertension is “a form of hypertension that progresses
rapidly, accompanied by severe vascular damage,” according
to Taber’s Cyclopedic Medical Dictionary, 19th Edition.
Malignant hypertension can be life threatening and may cause
a stroke, but is much less common than benign hypertension.
Common assumption: Because benign hypertension is
more common than malignant, physicians often assume they
are indicating benign hypertension when they simply write
“hypertension,” Prillaman says. But if the documentation
doesn’t specifically state “benign” or “malignant,”
the only accurate choice you have is to report an unspecified
code, she adds.
Bright idea: If your physicians aren’t keen
on always having to write “benign” or “malignant,”
you might try this: Institute a set policy within your practice
stating that, unless the physician specifies otherwise in
the chart, he is indicating benign hypertension whenever
he simply writes “hypertension,” Darling suggests.
Such a policy will allow you to rightfully move beyond “unspecified”
to report a more specific code.
3.
Identify primary or secondary
When documenting, physicians have to learn to link the patient’s
hypertension to any other manifestations, Darling says.
And coders have to learn to discern the manifestations properly
to assign the correct code.
Primary
hypertension
If the patient’s hypertension is primary, meaning that
another condition is not causing the hypertension, then
you need to list the hypertension code first. Then list
any manifestations as secondary diagnoses, Darling says.
However, patients sometimes have hypertension with another
condition, such as renal disease, and there is one code
that includes both conditions, she adds. For instance, the
403 code series indicates hypertensive renal disease, and
the 404 series indicates hypertensive heart and renal disease.
Example
#1: If your physician documents a patient with benign
hypertensive renal disease with renal failure, you would
report 403.11. You need only this one code to describe the
patient’s entire condition.
Example
#2: If your physician treats a patient with benign hypertensive
heart disease with heart failure, you would report 402.11.
This code indicates the patient’s entire hypertensive
status, but you would also need to report an additional
code to specify the type of heart failure, such as 428.0
(Congestive heart failure, unspecified).
Note: If the physician documents the patient has
heart disease due to hypertension, he should also indicate
whether the disease is with or without heart failure, Darling
says. “This [distinction] will help the coder select
the best code in the 402 or 404 categories,” she adds.
And if the patient does have heart failure, remember to
assign a separate code to indicate the type of heart failure.
Secondary
hypertension
A patient has secondary hypertension if the hypertension
is “due to” or caused by another condition. ICD-9-CM
defines secondary hypertension as “high arterial blood
pressure due to or with a variety of primary diseases, such
as renal disorders, CNS disorders, endocrine and vascular
diseases.”
For
secondary hypertension, you should report the causal condition
as the primary diagnosis and the hypertension as secondary.
For example, if a patient has primary aldosteronism that
is causing benign hypertension, you might report 255.10
(Primary aldosteronism) as the primary diagnosis and 405.19
(Secondary hypertension; benign; other) as the secondary.
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