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Check your diagnosis coding for this patient encounter. A patient presents today for a follow-up for her hypertension. At her last visit, she was complaining of swelling in her feet and ankles, back pain, trouble sleeping, and having to get up at night to urinate. She has a family history of chronic kidney disease (CKD). […]
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Our doctor just dictated it as hypertension, severe (I10).
Is there a standard range limit wherein it can just be hypertension (severe) vs hypertensive urgency?
Coder means well, goes by the book but sometimes gets a bit too enthusiastic about being the coding police.
Thanks!
A hypertensive crisis is a severe increase in blood pressure that can lead to stroke, organ damage, heart attack, and more. The Mayo Clinic defines extreme high blood pressure as “a top number (systolic pressure) of 180 millimeters of mercury (mm Hg) or higher or a bottom number (diastolic pressure) of 120 mm Hg or […]
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Our EMR puts past dx in the history and lets the provider activate it as needed. Our provider would deem its Hypertension and skip the HHD dx. Our coder comes back insisting that the provider click HHD. Our provider is in the opinion that she could code it from the past med hx.
Who is right?
Thanks.
Hypertensive heart disease refers to a group of disorders that includes heart failure, ischemic heart disease, and left ventricular hypertrophy. It is the number one cause of death associated with high blood pressure. Documentation must state (heart failure due to hypertension) or imply a causal relationship (hypertensive heart failure) to assign a code from category […]
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