Posted on 24. Feb, 2009 by in Toolkit
When you check the physician’s documentation for a hypertensive patient, don’t be surprised if you see other conditions listed.
Keep in mind: Sometimes patients have hypertension with another condition, such as renal disease or renal artery stenosis, and there is one code that includes both conditions, says Jaime Darling, CPC, a coder with Graybill Medical Group in Escondido, Calif.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 (Hypertensive chronic kidney disease; benign; with chronic kidney disease stage V or end stage renal disease). You need only this one code to describe the patient’s entire condition.
Example 2: If your physician treats a patient with benign hypertensive disease with heart failure, you would report 402.11 (Hypertensive heart disease; benign; with heart failure). This code indicates the patient’s entire hypertensive status. Note: You also would need to report an additional code to specify the type of heart failure, such as 428.0 (Congestive heart failure, unspecified).
Red flag: If your physician documents the patient has heart disease due to hypertension, he should also indicate whether the disease is with or without heart failure, according to Darling. “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.
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