ICD-10 codes are used to document and report medical diagnoses and procedures. Hypertension, also known as high blood pressure, is a common condition that affects many people worldwide. Here is a coding guide for coders to document and report hypertension diagnoses using ICD-10 codes:
- Start with the main code for hypertension, which is I10. This code should be used for all patients with hypertension, regardless of whether it is primary or secondary.
- If the hypertension is secondary, meaning it is caused by an underlying medical condition, then code both the underlying condition and the hypertension using additional codes. For example, if the patient has hypertension due to chronic kidney disease, you would code I12.0 (hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease) or I12.9 (hypertensive chronic kidney disease, unspecified).
- If the patient has pre-existing hypertension and becomes pregnant, use code O10.3 (pre-existing hypertension with pre-eclampsia) or O13.2 (pre-existing hypertension with superimposed pre-eclampsia) to indicate the pregnancy-related complication.
- If the patient has hypertensive heart disease, then use codes from category I11. This category includes codes for hypertensive heart disease with heart failure, with chronic kidney disease, and without heart failure or chronic kidney disease.
- If the patient has hypertensive retinopathy, then use code H35.0 (background retinopathy and hypertensive retinopathy).
- If the patient has hypertensive encephalopathy, then use code G93.0 (hypertensive encephalopathy).
- If the patient has isolated systolic hypertension, then use code I16.0 (hypertensive heart disease with pure systolic hypertension).
It is important to document the type and severity of hypertension in the medical record to ensure accurate coding. Additionally, it is important to stay up-to-date with any changes to coding guidelines to ensure accurate reporting.