How to Document and Code for Hypertensive Diseases in ICD-10

This installment in FPM's ICD-10 serial explains the guidelines for coding hypertension.

Fam Pract Manag. 2014 Mar-April;21(ii):5-9.

Author disclosure: no relevant fiscal affiliations disclosed.

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Commodity Sections

  • Introduction
  • Essential (chief) hypertension: I10
  • Hypertension and hypertensive heart affliction: I11
  • Hypertension and chronic kidney illness: I12
  • Hypertension, hypertensive center illness, and chronic kidney illness: I13
  • Tobacco use or exposure in individuals with hypertensive diseases
  • Coding for secondary hypertension: I15
  • Adapting to ICD-10
  • References

Because ICD-10 tin can be a deplorable topic, let's start with some adept news: Hypertension has a express number of ICD-10 codes – merely nine codes for main hypertension and five codes for secondary hypertension. This makes the task of coding hypertension relatively unproblematic – well, at to the lowest degree compared to some of the other ICD-10 complexities.

Another positive change in ICD-10 is that the new lawmaking set drops the previous reference to benign and malignant hypertension. As physicians, nosotros are well aware that hypertension is never truly "benign," and the removal of this antiquated term is a welcome improvement in the dictionary of diseases.

But, of form, goose egg is like shooting fish in a barrel in ICD-10, and there are several things you demand to exist enlightened of before nosotros dig into the codes themselves. For instance, the hypertensive disease codes in ICD-10 exclude several conditions: hypertension complicating pregnancy, neonatal hypertension, master pulmonary hypertension, and principal and secondary hypertension involving vessels of the brain or the eye. Postprocedural hypertension is also excluded from the secondary hypertension codes.

In improver, you lot'll need to exist careful throughout the "Diseases of the Circulatory Organisation" affiliate of ICD-ten to differentiate the capital letter "I" from the number "ane." The hypertension codes span from I10 to I15 (there is no I14), and each series has its own peculiarities, as this article will explain.

HYPERTENSIVE DISEASE ICD-10 CODES

This commodity contains several code lists and tables, which are available here for download as a single resource.

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Essential (primary) hypertension: I10

  • Abstruse
  • Essential (primary) hypertension: I10
  • Hypertension and hypertensive eye disease: I11
  • Hypertension and chronic kidney disease: I12
  • Hypertension, hypertensive heart disease, and chronic kidney disease: I13
  • Tobacco use or exposure in individuals with hypertensive diseases
  • Coding for secondary hypertension: I15
  • Adapting to ICD-10
  • References

In ICD-9, essential hypertension was coded using 401.0 (cancerous), 401.1 (benign), or 401.ix (unspecified). ICD-10 uses only a single code for individuals who meet criteria for hypertension and do non accept comorbid heart or kidney affliction. That lawmaking is I10, Essential (primary) hypertension.

As in ICD-9, this code includes "high blood pressure" only does not include elevated blood pressure without a diagnosis of hypertension (that would be ICD-x lawmaking R03.0). If a patient has progressed from elevated blood pressure to a formal diagnosis of hypertension, a expert documentation practice would be to include the reason for progressing the formal diagnosis. Similarly, a single mildly elevated blood pressure reading should be coded with the R03.0 until the formal diagnosis is established.

Although diverse sources define hypertension slightly differently, the provider should document elevated systolic pressure above 140 or diastolic force per unit area above 90 with at to the lowest degree two readings on carve up office visits. At that place are slight variations of this for older individuals and for individuals with readings obtained through ambulatory claret pressure monitoring. From a documentation viewpoint, it is merely important that the provider clearly document the basis for a newly established diagnosis.

Example: Your patient, a 55-year-old female, has had blood force per unit area readings between 130–135/80–85 for several years. At her annual examination, you tape her blood force per unit area as 144/92 and 142/90. You discuss with her the importance of following up and schedule some other appointment for ii weeks later. At that time, she again has several readings above 140/90, so you document the progression from prehypertension (R03.0) to essential hypertension (I10).

Hypertension and hypertensive heart disease: I11

  • Abstract
  • Essential (main) hypertension: I10
  • Hypertension and hypertensive heart illness: I11
  • Hypertension and chronic kidney disease: I12
  • Hypertension, hypertensive heart illness, and chronic kidney disease: I13
  • Tobacco use or exposure in individuals with hypertensive diseases
  • Coding for secondary hypertension: I15
  • Adapting to ICD-ten
  • References

When an individual has hypertension and eye disease, it is upward to the provider to determine whether at that place is a causal relationship stated or unsaid. This relationship determination is spelled out in the "Official Guidelines for Coding and Reporting" (draft 2014).1

The combination of hypertension and hypertensive heart affliction is currently coded using the ICD-nine 402.20 series of codes. Equally noted earlier, each category is currently divided into malignant, benign, and unspecified essential hypertension with or without eye failure. In ICD-10, this is narrowed to simply 2 base codes:

  • I11.0, Hypertensive center disease with heart failure,

  • I11.9, Hypertensive eye disease without heart failure.

The ICD-10 manual does not list the required documentation for hypertensive center disease. It is recommended, however, that the provider document the basis for the diagnosis (exam, electrocardiogram, echocardiogram, etc.) at least the first time this diagnosis is fabricated for the patient. It is not uncommon for patients with long-standing hypertension to develop some cardiac changes, only to code I11.nine instead of merely I10, the provider needs to document the support for doing so.

Unlike ICD-9, when you code hypertension with center failure (I11.0) using ICD-10, you are required to also lawmaking the blazon of heart failure from the I50 series:

  • I50.1, Left ventricular failure,

  • I50.two, Systolic (congestive) heart failure,

  • I50.3, Diastolic (congestive) heart failure,

  • I50.4, Combined systolic and diastolic heart failure,

  • I50.9, Heart failure, unspecified.

If you do non take a measurement of the left ventricular ejection fraction (typically from an echocardiogram), so you lot would need to use the more general left ventricular failure code (I50.ane).

The 3 codes for systolic, diastolic, and combined failure also require a fifth digit specifying the vigil of the diagnosis:

  • 0, Unspecified,

  • 1, Astute,

  • 2, Chronic,

  • 3, Acute on chronic.

Example: You lot have been post-obit a sixty-year-old male person with hypertension and mild centre failure. You have coded I11.0 and I50.9. He recently had an acute exacerbation of his center failure, was briefly hospitalized, and had an echocardiogram performed documenting combined systolic and diastolic failure. At discharge, you update his diagnosis codes to I11.0 and I50.43. When yous run into him in the office two weeks post-discharge and he is asymptomatic, his diagnosis codes could be I11.0 and I50.42 reflecting the chronic nature of his condition.

Hypertension and chronic kidney illness: I12

  • Abstract
  • Essential (primary) hypertension: I10
  • Hypertension and hypertensive middle disease: I11
  • Hypertension and chronic kidney disease: I12
  • Hypertension, hypertensive heart affliction, and chronic kidney disease: I13
  • Tobacco employ or exposure in individuals with hypertensive diseases
  • Coding for secondary hypertension: I15
  • Adapting to ICD-10
  • References

Different hypertension and center disease, where the provider must determine whether a causal relationship exists, if the patient has hypertension and develops chronic kidney disease, ICD-ten presumes a cause and effect relationship and classifies the condition every bit hypertensive chronic kidney affliction. Annotation, yet, that if the chronic kidney affliction came start, then the combination falls into the secondary hypertension codes discussed later in this commodity.

Both ICD-nine and ICD-10 require specifying the stage of the chronic kidney disease to properly code the condition. Very few patients have a truthful glomerular filtration charge per unit (GFR) measured and most staging relies on the estimated glomerular filtration rate (eGFR). Most laboratory reports provide a race-based reference range. Information technology is not uncommon for these estimates to have slight variability and for the patient's staging to vary between stage two and 3. Note that ICD-10 differentiates stage 5 from end-phase renal disease by the demand for chronic dialysis.

ICD-10 requires first using an I12 code for the combined diagnosis of hypertension and chronic kidney disease:

  • I12.0, Hypertensive chronic kidney disease with stage 5 chronic kidney disease or finish-phase renal illness,

  • I12.9, Hypertensive chronic kidney affliction with stage 1 through 4 chronic kidney disease or unspecified chronic kidney affliction.

These two codes require an additional N18 code to place the stage of kidney affliction, with documentation typically referencing the most recent eGFR:

  • N18.i, Chronic kidney disease, phase 1,

  • N18.ii, Chronic kidney affliction, stage 2 (mild),

  • N18.3, Chronic kidney disease, stage 3 (moderate),

  • N18.iv, Chronic kidney illness, phase iv (severe),

  • N18.v, Chronic kidney disease, stage v,

  • N18.6, Stop-stage renal disease,

  • N18.9, Chronic kidney disease, unspecified.

Example: You lot have been treating a 55-yearold black female for hypertension (I10) for the past five years. On her most recent office visit, you performed a comprehensive metabolic profile. All values were within the laboratory reference range except her BUN and creatinine. The laboratory calculated her eGFR at 40 (mL/min/1.73mii). Repeat testing produces a similar outcome. Yous update her diagnosis codes to I12.9 and N18.3.

Hypertension, hypertensive centre disease, and chronic kidney disease: I13

  • Abstract
  • Essential (master) hypertension: I10
  • Hypertension and hypertensive heart disease: I11
  • Hypertension and chronic kidney illness: I12
  • Hypertension, hypertensive middle affliction, and chronic kidney disease: I13
  • Tobacco use or exposure in individuals with hypertensive diseases
  • Coding for secondary hypertension: I15
  • Adapting to ICD-10
  • References

To confuse matters further, if the patient has all three conditions (hypertension, heart disease, and chronic kidney affliction), then you need to certificate the relationship between the hypertension and heart disease but assume the causal relationship between hypertension and chronic kidney disease. The documentation requirements are the same as what was outlined higher up.

The codes for the iii-disease combination are numerically bundled by the caste of chronic kidney illness rather than the presence or absence of heart failure:

  • I13.0, Hypertensive heart and chronic kidney disease with eye failure and with stage 1 through 4 chronic kidney affliction, or unspecified chronic kidney illness,

  • I13.ten, Hypertensive middle and chronic kidney disease without eye failure with stage i through stage 4 chronic kidney affliction, or unspecified chronic kidney disease,

  • I13.11, Hypertensive heart and chronic kidney illness without centre failure with stage v chronic kidney disease, or finish-phase renal affliction,

  • I13.2, Hypertensive eye and chronic kidney affliction with eye failure and with stage 5 chronic kidney disease, or stop-phase renal disease.

As with the ii-combination codes, all of the three-combination codes require additional coding from the N18 series to identify the stage of kidney disease. The three-combination codes that include heart failure also require additional coding from the I50 serial to specify the type and acuity of the failure.

Case: The 55-twelvemonth-quondam female in the above example presents to your role with some pedal edema, and on examination you lot also detect some mild crackles in the base of operations of her lungs. You guild an echocardiogram that documents mild systolic center failure. Her eGFR has remained stable. You update her diagnostic codes to I13.0 (Hypertensive center and chronic kidney disease with middle failure and with stage 1 through 4 chronic kidney disease, or unspecified chronic kidney illness), I50.21 (Systolic, congestive, heart failure, acute), and N18.3 (Chronic kidney disease, stage iii, moderate).

Tobacco employ or exposure in individuals with hypertensive diseases

  • Abstract
  • Essential (primary) hypertension: I10
  • Hypertension and hypertensive heart disease: I11
  • Hypertension and chronic kidney disease: I12
  • Hypertension, hypertensive heart disease, and chronic kidney affliction: I13
  • Tobacco use or exposure in individuals with hypertensive diseases
  • Coding for secondary hypertension: I15
  • Adapting to ICD-10
  • References

All of the hypertension codes require an additional ICD-10 code if the patient is a current or former tobacco user. In most cases, yous would use one of the following codes establish in chapter v, "Mental, Behavioral, and Neurodevelopmental Disorders":

  • F17, Nicotine dependence,

  • F17.twenty, Unspecified,

  • F17.21, Cigarettes,

  • F17.22, Chewing tobacco,

  • F17.29, Other tobacco product.

Each of these four categories has a required sixth grapheme:

  • 0, simple,

  • 1, in remission,

  • iii, with withdrawal,

  • 8, with other specified nicotine-induced disorder,

  • nine, with unspecified nicotine-induced disorder.

If you accept not documented that a patient who uses tobacco is "dependent," then y'all would instead utilise the code for tobacco use (Z72.0). The deviation is not well-defined, but the Centers for Disease Control and Prevention's website states, "Tobacco use can lead to tobacco/nicotine dependence and serious wellness bug … Tobacco/nicotine dependence is a chronic condition that frequently requires repeated interventions."

Occupational and environmental exposure to tobacco should also be coded if the provider believes these are influencing the patient'southward health status. The codes are as follows:

  • Z57.31, Occupational exposure to ecology tobacco smoke,

  • Z72.0, Issues related to lifestyle, tobacco use,

  • Z77.22, Exposure to environmental tobacco smoke (includes 2d-hand smoke exposure and passive smoking),

  • Z87.891, Personal history of nicotine dependence.

The ICD-x manual partially explains the departure betwixt Z87.891, "Personal history of nicotine dependence," and F17.211, "Nicotine dependence, cigarettes, in remission." It states that a personal history code should exist 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."

Coding for secondary hypertension: I15

  • Abstract
  • Essential (primary) hypertension: I10
  • Hypertension and hypertensive heart disease: I11
  • Hypertension and chronic kidney disease: I12
  • Hypertension, hypertensive heart disease, and chronic kidney affliction: I13
  • Tobacco use or exposure in individuals with hypertensive diseases
  • Coding for secondary hypertension: I15
  • Adapting to ICD-10
  • References

Although the main focus of this article has been essential hypertension, including comorbidities of centre failure and chronic kidney illness, there may be some patients in the primary intendance setting who have hypertension secondary to other illness states. In these cases, providers cannot use the hypertension ICD-ten codes discussed above. Instead, use the following codes:

  • I15.0, Renovascular hypertension,

  • I15.ane, Hypertension secondary to other renal disorders,

  • I15.2, Hypertension secondary to endocrine disorders,

  • I15.8, Other secondary hypertension,

  • I15.nine, Secondary hypertension, unspecified.

The five secondary hypertension codes require that yous also lawmaking the underlying condition. ICD-10 typically permits either the underlying status or the secondary hypertension code to be listed first depending on the reason for the patient encounter. The exception to this is I15.eight, Other secondary hypertension. Considering this is an "other" code, the "other" condition must be coded start.

Adapting to ICD-x

  • Abstract
  • Essential (master) hypertension: I10
  • Hypertension and hypertensive center affliction: I11
  • Hypertension and chronic kidney illness: I12
  • Hypertension, hypertensive centre illness, and chronic kidney affliction: I13
  • Tobacco use or exposure in individuals with hypertensive diseases
  • Coding for secondary hypertension: I15
  • Adapting to ICD-10
  • References

If this introduction to the new hypertension codes has elevated your blood pressure, stop and accept a deep breath. ICD-10 coding is a big adjustment, merely it volition become easier with time and practice. For more help, see the series overview and look for hereafter articles in FPM.

Manufactures IN FPM'S ICD-10 SERIES

Y'all tin access the following articles in FPM's ICD-x topic collection:

"ICD-10: Major Differences for V Common Diagnoses," FPM, September/October 2015.

"ICD-10 Sprains, Strains, and Automobile Accidents," FPM, May/June 2015.

"Digesting the ICD-ten GI Codes," FPM, January/Feb 2015.

"Coding Common Respiratory Problems in ICD-10," FPM, Nov/Dec 2014.

"ICD-10 Simplifies Preventive Care Coding, Sort Of," FPM, July/August 2014.

"ICD-10 Coding for the Undiagnosed Trouble," FPM, May/June 2014.

"How to Certificate and Code for Hypertensive Diseases in ICD-ten," FPM, March/April 2014.

"10 Steps to Preparing Your Office for ICD-x – Now," FPM, January/February 2014.

"Getting Ready for ICD-ten: How It Volition Affect Your Documentation," FPM, Nov/December 2013.

"The Anatomy of an ICD-10 Code," FPM, July/August 2012.

"ICD-ten: What You Need to Know Now," FPM, March/April 2012.

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Nearly the Author

Dr. Beckman, a family md, is vice president/principal medical officer for a health insurance company in Milwaukee, Wis.

Writer disclosure: no relevant financial affiliations disclosed.

Copyright © 2014 by the American Academy of Family Physicians.
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