I have a cardiology office visit case wherein the Problem List in the medical documentation states, among many other conditions, "Hypertension, hard to control secondary to left ventricular noncomliance and aortic inelasticity." However, later on, in the assessment, it is stated, "Blood pressure well controlled."

My inclination was to code secondary hypertension, e.g., I15.8 Other secondary hypertension (although I’m not sure how I would report left ventricular noncompliance or aortic inelasticity). However, another coder stated that, since the assessment indicates "blood pressure well controlled," I should simply report I10.

Is this good advice? If so, why? Is it because it’s well controlled (doubt that’s a good reason), or is it simply because in the assessment, the doctor chose not to characterize the hypertension as secondary?

Thanks,

Jim Shaw, CPC-A