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Coding Hypertension and Hyperlipidemia

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1 Coding Hypertension and Hyperlipidemia
Beth Sassano CCS-P, CPC, CPC-I, CPMA

2 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.

3 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 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.

4 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 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.

6 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.

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

8 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 , hypertensive retinopathy then report the correct hypertension code from 401.x-405.x to indicate the type of hypertension.

9 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 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.

10 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.

11 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.

12 ICD-10 Hypertensive 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

13 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.

14 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.

15 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).

16 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.

17 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

18 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)

19 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 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)

20 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.

21 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.

22 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

23 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

24 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.

25 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 2 Tobacco 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: Z Occupational exposure to environmental tobacco smoke, Z Problems related to lifestyle, tobacco use, Z Exposure to environmental tobacco smoke (includes second-hand smoke exposure and passive smoking), Z Personal history of nicotine dependence.

26 Nicotine/Tobacco use or exposure in patients with HTN
Z Is Personal history of nicotine dependence F 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.””

27 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

28 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) I with heart failure I with stage 1 through stage 4 chronic kidney disease I with stage 5 or end stage renal disease I without heart failure I with stage 1 through stage 4 chronic kidney disease I with stage 5 or end stage renal disease I cardiovascular disease (arteriosclerotic) (sclerotic) - see Hypertension, heart renal (disease) - see Hypertension, cardio renal chronic venous - see Hypertension, venous (chronic) complicating childbirth (labor) O with heart disease O with renal disease O renal disease O with heart disease O essential O secondary O10.42 pregnancy O with edema - see also Pre-eclampsia O gestational (pregnancy induced) (transient) ( without proteinuria) O with proteinuria O mild pre-eclampsia O moderate pre-eclampsia O severe pre-eclampsia O with hemolysis, elevated liver enzymes and low platelet count (HELLP) O pre-existing O with heart disease O with renal disease O pre-eclampsia O renal disease O with heart disease O essential O secondary O puerperium, pre-existing O with heart disease O with renal disease O renal disease O with heart disease O essential O pregnancy-induced O13.9 secondary O10.43

29 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) (transient) O13.- with significant proteinuria - see Pre-eclampsia Goldblatt's I70.1 heart (disease) (conditions in I51.4-I51.9 due to hypertension) I11.9 with heart failure (congestive) I11.0 kidney disease (chronic) - see Hypertension, c ardiorenal intracranial (benign) G93.2 kidney I12.9 with heart disease - see Hypertension, cardiorenal stage 5 chronic kidney disease (CKD) or end stage renal 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 H pancreatic 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 postoperative I97.3 psychogenic F45.8 pulmonary (artery) (secondary) I with cor pulmonale (chronic) I acute I right heart ventricular strain/failure I acute I of newborn (persistent) P primary (idiopathic) I27.0 renal - see Hypertension, kidney renovascular I15.0 secondary NEC I due to endocrine disorders I pheochromocytoma I renal disorders NEC I arterial I renovascular disorders I specified NEC I15.8 venous (chronic) due to deep vein thrombosis - see Syndrome, postthrombotic idiopathic I with inflammation I with ulcer I specified complication NEC I ulcer I with inflammation I asymptomatic I87.30-

30 Hypertension Fast Finder

31 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.

32 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.

33 Hyperlipidemia in ICD-9
When ICD-10 goes into effect in 2015, high cholesterol will 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

34 Hyperlipidemia in ICD-10
E78.0, Pure hypercholesterolemia E78.1, Pure hyperglyceridemia E78.2, Mixed hyperlipidemia E78.4, Other hyperlipidemia E78.5, Hyperlipidemia, unspecified

35 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).

36 The End THANK YOU

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