Understand anatomy to transition reporting hypertension from ICD-9-CM to ICD-10-CM

By Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-Approved ICD-10-CM/PCS Trainer

 
According to the Centers for Disease Control and Prevention (CDC), 31% of all American adults--67 million people--have high blood pressure. These numbers include more women than men and a greater prevalence in those over 65 years of age.
 
According to the CDC, normal blood pressure readings are systolic of less than 120 mmHg and diastolic of less than 80mmHg. Patients with a systolic pressure of 120–139 mmHg and a diastolic of 80–89 mmHg are considered at risk.
 
Patients with a systolic pressure of 140 mmHg or higher and a diastolic pressure of  90 mmHg or higher have high blood pressure.
 
When the physician documents the patient has an elevated blood pressure reading, but does not include a diagnosis of hypertension, coders report ICD-9-CM code 796.2 (elevated blood pressure reading without diagnosis of hypertension). In ICD-10-CM, they will report R03.0 (elevated blood pressure reading without diagnosis of hypertension).
 
Primary hypertension
Patients frequently show no signs and symptoms of hypertension, other than continuous high blood pressure measurements, until the condition alters vascular function in the heart, brain, and/or kidneys.
 
Hypertension causes the heart to work harder than normal and can result in left ventricular hypertrophy. It can subsequently cause left-sided heart failure, right-sided heart failure, and/or pulmonary edema [excess fluids in the tissues].
 
A diagnosis will typically come from trending--charting the readings over time (an excellent tool in most electronic health records software programs). In addition, a physician can support a diagnosis of hypertension with other data, including:
  • Auscultation (listening to sounds with a stethoscope) over the abdominal aorta as well as the carotid, renal, and femoral arteries that reveals bruits (an abnormal sound created by blood flowing past an obstruction; also known as turbulent flow)
  • Ophthalmoscopy that makes arteriovenous nicking visible
  • Patient history that includes a family history of hypertension
  • Chest x-ray that reveal cardiomegaly (enlargement of the heart)
  • Echocardiography showing left ventricular hypertrophy [hyper = high or over + -trophy = growth]
  • Electrocardiogram (ECG or EKG) showing ischemia (shortage of oxygen due to reduced or restricted blood flow)
 
When the documentation includes a specific diagnosis of hypertension, coders need more information to accurately report this diagnosis.
 
A diagnosis of essential hypertension, hyperpiesia, hyperpiesis, hypertension (arterial)(essential)(primary)(systemic), hypertensive vascular degeneration, or hypertensive vascular disease will be reported as follows:
 

ICD-9-CM
ICD-10-CM
401.0 Malignant essential hypertension
 
401.1 Benign essential hypertension
 
401.9 Unspecified essential hypertension
I10 Essential (primary) hypertension

 
ICD-10-CM eliminates the need to qualify this diagnosis as benign or malignant. In addition, ICD-10-CM includes fewer unspecified codes. If the physician does not document a specific piece of information, you must query the physician to have the missing information added to the record, so you can report an accurate, specific code.
 
Hypertensive heart disease
A patient may heart disease or heart failure as a direct result of having hypertension. If the physician documents hypertensive heart disease or a heart condition due to hypertension, report one of the following combination code:
 

ICD-9-CM
ICD-10-CM
402.00 Hypertensive heart disease, malignant without heart failure
 
402.01 Hypertensive heart disease, malignant with heart failure
 
402.10 Hypertensive heart disease, benign without heart failure
 
402.11 Hypertensive heart disease, benign with heart failure
 
402.90 Hypertensive heart disease, unspecified without heart failure
 
402.91 Hypertensive heart disease, unspecified with heart failure
I11.0 Hypertensive heart disease with heart failure (hypertensive heart failure)
 
I11.9 Hypertensive heart disease without heart failure (hypertensive heart disease NOS)

 
Both ICD-9-CM and ICD-10-CM include a notation directing you to “Use additional code to identify type of heart failure.” This applies only in those cases where the physician documents heart failure.
 
When the physician documents hypertension and a heart condition with no specific cause-and-effect identifying that the heart condition was caused by the hypertension, do not use a code from code category 402 or I11.
In these cases, you are to code these two conditions separately using 401.x or I10 and the code for the heart condition.
 
Hypertensive chronic kidney disease
When the physician documents a diagnosis of hypertensive chronic kidney disease, report a combination code, as appropriate.
 
In these cases, the physician does not need to document a cause-and-effect between the hypertension and the kidney disease. The mere existence of both conditions in the same body at the same time is enough to report them together.
 
You will need the documentation to specify the stage of the chronic kidney disease to determine the correct code in either ICD-9-CM or ICD-10-CM.
 

ICD-9-CM
ICD-10-CM
403.00 Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage 1 through stage IV or unspecified
 
403.01 Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease
 
403.10 Hypertensive chronic kidney disease, benign, with chronic kidney disease stage 1 through stage IV or unspecified
 
403.11 Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end stage renal disease
 
403.90 Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage 1 through stage IV or unspecified
 
403.91 Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease
I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease
 
I12.9 Hypertensive chronic kidney disease with stage 1 through 4 chronic kidney disease or unspecified chronic kidney disease

 
Both ICD-9-CM and ICD-10-CM include a notation directing you to “Use additional code to identify the stage of chronic kidney disease.
 
Hypertensive heart and chronic kidney disease
When the physician documents both hypertensive chronic kidney disease and hypertensive heart disease, you need to confirm that a cause-and-effect is specified for the hypertension and the heart condition. When this is the case, you have another combination code to use:
 

ICD-9-CM
ICD-10-CM
404.00 Hypertensive heart and chronic kidney disease, malignant, without heart failure and with chronic kidney disease stage 1 through stage IV or unspecified
 
404.01 Hypertensive heart and chronic kidney disease, malignant, with heart failure with chronic kidney disease stage 1 through stage IV or unspecified
 
404.02 Hypertensive heart and chronic kidney disease, malignant, without heart failure and with chronic kidney disease age 5 chronic kidney disease or end stage renal disease
 
404.03 Hypertensive heart and chronic kidney disease, malignant, with heart failure with chronic kidney disease age 5 chronic kidney disease or end stage renal disease
 
404.10 Hypertensive heart and chronic kidney disease, benign, without heart failure with chronic kidney disease stage 1 through stage IV or unspecified
 
404.11 Hypertensive heart and chronic kidney disease, benign, with heart failure and with chronic kidney disease stage 1 through stage IV or unspecified
 
404.12 Hypertensive heart and chronic kidney disease, benign, without heart failure with chronic kidney disease stage V or end stage renal disease
 
404.13 Hypertensive heart and chronic kidney disease, benign, with heart failure and with chronic kidney disease stage V or end stage renal disease
 
404.90 Hypertensive heart and chronic kidney disease, unspecified without heart failure and with chronic kidney disease stage 1 through stage IV or unspecified
 
404.91 Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage 1 through stage IV or unspecified
 
404.92 Hypertensive heart and chronic kidney disease, unspecified without heart failure and with chronic kidney disease stage V or end stage renal disease
 
404.93 Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage V or end stage renal disease
I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through 4 chronic kidney disease or unspecified chronic kidney disease
 
I13.10 Hypertensive heart and chronic kidney disease without heart failure and stage 1 through 4 chronic kidney disease or unspecified chronic kidney disease
 
I13.11 Hypertensive heart and chronic kidney disease without heart failure with stage 5 chronic kidney disease or end stage renal disease
 
I13.2 Hypertensive heart and chronic kidney disease with heart failure with stage 5 chronic kidney disease or end stage renal disease
 
 

 
Both ICD-9-CM and ICD-10-CM include notes directing you to:
  • Use additional code to identify type of heart failure (when the provider documents the type of heart failure)
  • Use additional code to identify the stage of chronic kidney disease
 
Secondary hypertension
Some patients have hypertension as a result of another disease or perhaps as a side effect of medication taken for another condition. In these cases, the hypertension is reported as secondary.
           
The involvement of renal disease as an underlying cause of the hypertension, also known as renovascular hypertension, may be diagnosed as a result of testing, including:
  • Urinalysis showing protein levels and red and white blood cells indicating glomerulonephritis (inflammation of small blood vessels in the kidneys)
  • Excretory urography that reveals renal atrophy (wasting away of a kidney) pointing to chronic renal disease or a shortening of one kidney that may indicate unilateral renal disease
  •  Serum potassium levels (blood tests measuring the levels of potassium in the blood)] below the normal measure of 3.5 mEq/L that can indicate primary hyperaldosteronism  

ICD-9-CM
ICD-10-CM
405.01 Malignant secondary hypertension due to a renovascular condition
 
405.09 Malignant secondary hypertension due to another condition
 
405.11 Benign secondary hypertension due to a renovascular condition
 
405.19 Benign secondary hypertension due to another condition
 
405.91 Unspecified secondary hypertension due to a renovascular condition
 
405.99 Unspecified secondary hypertension due to another condition
I15.0 Renovascular hypertension
 
I15.1 Hypertension secondary to other renal disease
 
I15.2 Hypertension secondary to endocrine disorders
 
I15.8 Other secondary hypertension
 
I15.9 Secondary hypertension, unspecified

 
Coders are directed to “Code also underlying condition.” Note that sequencing is not identified in this notation. Report them based on the sequencing guidelines in the Official Guidelines for Coding and Reporting, Section II.
 
Editor’s note: Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, Fla., is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee. E-mail her at ssafian@embarqmail.com.

 

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