Hypertension:
A. Hypertension with heart disease
Hypertension and heart disease should be coded as related even though it's not documented in the medical record as related, Assign a code from category I11 (Hypertensive
heart disease) with additional code from category I50
If the provider document there is no
relationship between hypertension and heart disease, then code separately (Two codes), the code sequence is based on the reason for the encounter.
B. Hypertension with chronic kidney disease
If hypertension
and chronic kidney diseases are present, assign a code from category I12
(Hypertensive chronic kidney disease) with additional code from category N18
(Stage of CKD)
If the provider document there is no relationship between hypertension and kidney disease, then code separately (Two codes), the code sequence is based on the reason for the encounter.
C. Hypertension with heart and chronic kidney disease
If a patient is
having hypertension, chronic kidney disease and heart disease, Assume the
relationship and Assign combination code from category I13, with additional
codes for the type of heart failure (I50) and stage of CKD (N18).
D. Hypertension, Secondary
Hypertension is
due to an underlying condition. Two codes are required, one code for etiology
and another code from category I15 for secondary hypertension.
E. Hypertension, controlled / uncontrolled
Uncontrolled
refer to hypertension not responding to current medication.
Assign the
appropriate code from categories I10-I15
F. Hypertension, Transient
If there is no
established diagnosis of hypertension code only R03.0 (Elevated blood
pressure).
G. Hypertension Crisis
Assign I16 (Hypertensive crisis) for Hypertensive urgency, hypertension emergency or an unspecified hypertensive crisis.
Atherosclerotic coronary artery disease and angina:
Combination
codes for atherosclerotic heart disease with angina pectoris.
Subcategories
I25.11 (Atherosclerosis heart disease of the native coronary
artery with angina pectoris)
I25.7
(Atherosclerosis heart disease of coronary artery bypass graft with
angina pectoris) - Don't code angina code separately.
A causal relationship can be assumed in a patient with both atherosclerotic coronary artery disease and angina is documented, unless it indicated the angina is due to some other reason.
Patient with coronary artery disease admitted due to Acute Myocardial Infarct; code AMI as first Dx followed by CAD.
Sequelae of cerebrovascular disease:
Category I69 is used to indicate conditions classifiable to categories
I60-I67 as the causes of sequela. These late effects include neurologic
deficits that persist after the onset of conditions classifiable to categories
I60-I67
Category I69 is used along with I60-I67 if the patient
has a current cerebrovascular disease and deficits from an old cerebrovascular
disease.
Use
appropriate history codes for H/o TIA and cerebral
infarction.
Category I69 and I60-I67 may be reported together if current CVA and deficit from an old CVA are documented.
Personal History codes (Z86.73) - Don't code category I69 if the patient doesn't have a neurologic deficit.
Acute Myocardial Infarction (AMI):
If encounter
occurring while the MI is less than four weeks old, assign from category I21
Encounter after
the 4th week, appropriate aftercare should be used not the I21
For old/healed
MI, assign I25.2 (old myocardial infarction)
Subsequent acute myocardial infarction
A code from
category I22, to be used when a patient who has suffered an AMI has a new AMI (Type 1 or Unspecified) within the 4 week time of the initial AMI
- For Subsequent Type 2 AMI - I21.A1
- For Subsequent Type 4 or 5 AMI - I21.A9
Both category
codes (I22 and I21) must be used together if both the initial and subsequent myocardial infarcations are type 1 or unspecified.
Subcategories
I21.0 - I21.2 and I21.3 used for STEMI
Subcategories
I21.4 used for NSTEMI
Note: If NSTEMI evolves to STEMI – code the STEMI
If STEMI
converts to NSTEMI due to thrombolytic therapy – code as STEMI
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Test your knowledge:
A. Chapter 9 & 10 ICD 10 CM Quiz