Heart - Circulatory System

Coding Hypertension and Heart Disease:

If a patient has both hypertension and heart disease, knowing whether the heart disease was a by product of high blood pressure or not is important. Because you cannot presume the heart disease has been caused by the hypertension. That is not allowed. If the physician specifically states that both are connected, then you choose a code from the category I11.

If there is no such documentation available, you simply code the conditions separately sequencing them according to the circumstances of admission.

Coding Hypertension and Chronic Kidney Disease:

Now this is a different scenario. You need to assume that Hypertension and CKD are connected even if there is no such documentation by the doctor. You need to choose a code from the category I12 when both conditions are simultaneously present.

Hypertensive heart and CKD:

A single code from I13 indicates the patient has both hypertensive heart disease and hypertensive CKD. So you just are allowed to assume a relationship between the HTN and CKD.

A Reminder:

Never assume that elevated or transient spike in blood pressure is hypertension. It is very important to use a code from the category R03.0 when documentation does not explicitly state the patient is hypertensive. The reason is in order to confirm hypertension, repeated high blood pressure readings over a period of time is needed to make a diagnosis. Just a random spike in blood pressure does not warrant the code I10.

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