Essential (primary) hypertension: I10

In ICD-9, essential hypertension was coded using 401.0 (malignant), 401.1 (benign), or 401.9 (unspecified). ICD-10 uses only a single code for individuals who meet criteria for hypertension and do not have comorbid heart or kidney disease. That code is I10, Essential (primary) hypertension.

As in ICD-9, this code includes “high blood pressure” but does not include elevated blood pressure without a diagnosis of hypertension (that would be ICD-10 code R03.0). If a patient has progressed from elevated blood pressure to a formal diagnosis of hypertension, a good 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.

Code I10 includes high blood pressure, but it does not include elevated blood pressure reading without a diagnosis of HTN. The definition of HTN may vary, but it is recommended that the provider document elevated systolic pressure above 140 or diastolic pressure above 90 with at least two readings during different office visits. Documentation should clearly identify the basis for a newly established diagnosis of HTN

Hypertension and hypertensive heart disease: I11

When an individual has hypertension and heart disease, it is up to the provider to determine whether there is a causal relationship stated or implied. This relationship determination is spelled out in the “Official Guidelines for Coding and Reporting” (draft 2014).1The combination of hypertension and hyper-tensive heart disease is currently coded using the ICD-9 402.xx series of codes. As noted earlier, each category is currently divided into malignant, benign, and unspecified essential hypertension with or without heart failure. In ICD-10, this is narrowed to only two base codes:

• I11.0, Hypertensive heart disease with heart failure,
• I11.9, Hypertensive heart disease without heart failure.

“Hypertension with heart conditions classified to I50.– or I51.4-I51.9, are assigned to a code from category I11, Hypertensive heart disease. Use an additional code from category I50, heart failure, to identify the type of heart failure in those patients with heart failure.”

HTN has an assumed relationship with these heart conditions (I50.-, I51.4-I51.9). They are coded as related unless the provider specifically documents a different cause for the heart condition. The code sequence will depend on the circumstances of the omission/encounter.

Hypertension ICD 10 – classification

Hypertension, essential (primary) I10
Hypertensive heart disease I11.
-W/ heart failure I11.0
W/out heart failure I11.9
Hypertensive CKD I12.
-W/CKD stage 5 or end-stage renal disease (ERSD) I12.0
W/CKD stage 1-4 or unspecified chronic kidney disease (CKD) I12.9
Hypertensive heart and CKD I13.
-W/heart failure and CKD stage 1-4 or unspecified CKD I13.0
W/out heart failure and CKD stage 1-4 or unspecified CKD I13.10
W/out heart failure and CKD stage 5 or ESRDI 13.11
W/heart failure and CKD stage 5 or ESRDI 13.2

Hypertension With Heart Disease

ICD-10-CM guideline I.C.9.a.1 states:

Hypertension with heart conditions classified to I50.- or I51.4-I51.7, I51.89, I51.9, are assigned to a code from category I11, Hypertensive heart disease. Use addition-al code(s) from category I50, Heart failure, to identify the type(s) of heart failure in those patients with heart failure. The same heart conditions (I50.-, I51.4-I51.7, I51.89, I51.9) with hypertension are coded separately if the provider has documented they are unrelated to the hypertension. Sequence according to the circumstances of the admission/encounter,

Now turn to I50 Heart failure in your code book (page 678 in AAPC’s ICD-10-CM Expert code book). Notice the instructional note here states code first heart failure due to hypertension … followed by a list of codes and descriptions.

In other words, you should code the hypertension (I11.-) and then the heart failure (I50.-). Make sure you are coding heart failure to the highest level of specificity documented. But don’t forget the guideline states “sequence according to the circumstances of the admission/encounter.”

Hypertension, Secondary

ICD-10-CM guideline I.C.9.6 states, “Secondary hypertension is due to an underlying condition. Two codes are required: one to identify the underlying etiology and one from category I15 to identify the hypertension. Sequencing of codes is determined by the reason for admission/encounter. ”An instructional note in the Tabular List for I15.- states to “code also the underlying condition.

Pulmonary Hypertension

ICD-10-CM guideline I.C.9.11 states, “Pulmonary hypertension is classified to category I27, Other pulmonary heart diseases. For secondary pulmonary hypertension (I27.1, I27.2-), code also any associated conditions or adverse effects of drugs or toxins. The sequencing is based on the reason for the encounter, except for adverse effects of drugs (See Sec t ion I.C .19.e.).”

Example: A patient presents to the cardiologist for hypertension and chronic diastolic heart failure. The patient has a social history of former smoker who quit one year ago after 30 years of smoking cigarettes. The provider has documentation to support both diagnoses were addressed at the encounter.I11.0 Hypertensive heart disease with heart failureI50.32 Chronic diastolic (congestive) heart failure 8 7. 8 9 1 Personal history of nicotine dependence

Clinical coding and documentation tips

›Explicitly document findings to support the diagnosis of HTN and the current manifestations when applicable. Secondary diagnoses, such as systolic/diastolic heart failure and/or chronic kidney disease,

›There is no need to document multiple hypertensive codes sets, such as I10 (essential HTN), I11 (hypertensive heart disease), I12 (hypertensive chronic kidney disease), and I13 (hypertensive heart and chronic kidney disease). One code set that details the highest level of patient specificity is sufficient,

›If chronic kidney disease (CKD) is linked to HTN, then clinicians need to document the stage of CKD using the (N18) code set.

›If congestive heart failure is linked to congestive heart failure (CHF), then clinicians need to document the type of heart failure using the (I50) code set.

›Document diagnostic statements that are compatible with the ICD-10 nomenclature,

›Confirm face-to-face encounter is signed and dated by clinician. Include printed version of clinician’s full name and credentials (e.g., MD, DO, NP, PA),

›A chronic disease, like HTN, must have a valid treatment plan in order to be considered an active medical problem. Treatment plans can be in the form of a: medication, referral, diet, monitoring, and/or ordering a diagnostic exam. The goals of therapy are as follows:
• In persons over the age of 60 the blood pressure goal is suggested to be < 150/90mmHg.
• For patients that are 60 years and older treatment should be started when systolic blood pressure (SBP) is ≥ 150mmHg or diastolic blood pressure (DBP) is ≥ 90mmHg.
• In persons less than the age of 60 the blood pressure goal is suggested to be < 140/90.
• For patients less than 60 years of age treatment should be started when DBP is ≥ 90mmHg.
• Suggested JNC 8 treatment to consider include (disclaimer – these recommendations should not supplant clinical judgment, patient circumstances or preferences).

• Evidenced based treatments for selective populations
• African Americans with or without diabetes: Calcium channel blockers (CCB) & thiazide diuretics
• Non-African Americans: Angiotensin – converting enzymes (ACE), Angiotensin receptor blockers (ARB), thiazide diuretics, & CCB
• Chronic kidney disease: ACE or ARB

›Heart failure: ACE or ARB

›Diabetics, non-African American: thiazide diuretics, CCB, ACE, or ARB should be considered.

›Start one drug and titrate to maximum dose prior to adding a second drug. Use the lowest dose possible to achieve the desired therapeutics effect.

›Do not use an ACE and an ARB in combination on the same patient. If blood pressure is not controlled after adding a third drug consider, referral to a hypertension specialist.

›Be wary of orthostatic blood pressure occurrences in those that are elderly, as this may cause patients to fall.

›Non-pharmacological: • Diet, • Exercise, • Weight loss
• Salt restriction with a goal of less than 3000mg daily.
• Encourage the patient to measure their blood pressure at home using an arm cuff.