If heart failure is present, a third code is used to identify the type of heart failure (diastolic, systolic, left ventricular, combined diastolic or systolic).Įxample: A patient is admitted with acute diastolic heart failure due to hypertension with end stage renal disease (ESRD). A second code is used to identify the stage of CKD. The relationship is assumed between hypertension and CKD, but must be implied or stated for hypertension and heart disease. I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal diseaseĬategory I13, hypertensive heart and chronic kidney disease, is assigned when both hypertensive heart and hypertensive chronic kidney disease are documented in the medical record.A secondary code is needed to identify the stage of CKD.Įxample: A patient with malignant hypertension and stage 5 CKD is admitted to the emergency room with elevated BP and edema. The coding guidelines state an assumed relationship when both hypertension and chronic kidney disease (CKD) are documented. I11.9 Hypertensive heart disease without heart failureĬategory I12, hypertension and chronic kidney disease, is assigned for hypertensive chronic kidney disease.Labs will be drawn and he will follow-up in three months.

He has no chest pain, no complaints and blood pressure (BP) readings at home are normal. Use a second code to identify the type of heart failure, if present.Įxample: A patient is seen for a three-month check-up for hypertensive heart disease. I13 Hypertensive heart and chronic kidney diseaseĬategory I11, hypertension with heart disease, is assigned when a causal relationship is stated or implied in documentation, such as hypertensive heart disease or heart disease due to hypertension.I12 Hypertension and chronic kidney disease.I10 Hypertension (benign, essential, primary).The concept of controlled and uncontrolled are not a part of the coding choice, although good clinical documentation should include the status of the patient and the type of hypertension being treated.Ĭombination codes have been created to report hypertension with associated conditions. In ICD-10, the diagnosis codes are simplified and the hypertension table is no longer necessary. In ICD-9, diagnosis code selection in category 401 is based on the type of hypertension treated: benign, essential, primary, malignant or unspecified. Hypertension is a common condition treated in most practices. This month’s tip comes from Peggy Stilley, the Director of ICD-10 Development and Training for AAPC, a training and credentialing association for the business side of health care. CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing.

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