Special Report: Hypertension Coding
Drug Coding Advisor: Hypertension presents unique coding challenge
Hypertension coding can pose problems for MDs and coders
(Editor’s note: Hypertension coding can be challenging for coders, especially when physician diagnoses lack the detail necessary to obtain the most precise codes. This two-part DRG Coding Advisor series on hypertension coding offers suggestions about how coders can overcome obstacles through better communication with physicians and better understanding of hypertension diagnostics. Look in the January 2003 issue of Hospital Payment & Information Management’s DRG Coding Advisor for an article on how coders can learn more about coding diagnostics and for a hypertensive disease coding chart.)
Too often, a physician’s charts will stop at the word "hypertension," leaving the details for coders to obtain through careful detective work.
"What we need to communicate to doctors are the elements required for a complete and accurate diagnosis of hypertension," says Kelly Butler, MD, CCS, owner of Dr. Coder & Associates of Murray, UT. Butler spoke about coding essential hypertension and target organ disease at the 74th National Convention and Exhibit of the American Health Information Management Association of Chicago, held Sept. 21-26 in San Francisco.
Hypertension is just the beginning’
"Twenty years into DRGs and we’re still not teaching doctors about one of our most common diagnoses: hypertension," Butler says. "Hypertension is just the beginning of the diagnosis."
There are three other elements that are needed once a physician writes the word "hypertension," Butler says. "We need them to say what is the degree of control or lack of control," she says. "If it’s controlled, then it’s OK, but if it’s uncontrolled, then we need to know how severely it is out of control, and they need to use terms like malignant’ and crisis.’"
Also, it’s important that physicians document whether there are any organ disease problems affecting the brain, heart, vascular system, renal system, and retina, and how severe these problems are, Butler says.
For example, if there is renal involvement, it could be either renal failure or renal insufficiency, Butler adds. "And we need to explain to doctors that insufficiency and failure are not the same things," she says.
Let physicians know what you need
Butler offers these tips for improving hypertension coding:
1. Let physicians know what you need in order to code correctly.
Physicians need to document whether there is a medical necessity for the patient to be seen, as well as the severity of illness, because the severity of illness with hypertension probably is grossly underreported, Butler says.
"This is a way we justify those expensive services we have for the patient," Butler notes. "Not only for the DRG assignment does it give the greater severity and higher illness, but also for evaluation and management and office billing."
Physicians might note any of these clinical findings, which offer clues to the severity of the disease, Butler says:
- Symptoms: Headache, which usually occurs only with stage 3 in the sub-occipital region; dizziness; palpitations; confusion; easy fatigability; somnolence; impotence; blurred vision; nausea and vomiting.
- Heart: Left ventricular hypertrophy (LVH); severe LVH disposes to myocardial ischemia, ventricular arrhythmias, and sudden death; exertional and/or paroxysmal nocturnal dyspnea are possible.
- Brain: Stroke: due to thrombosis; hemorrhage from microaneurysms of penetrating arteries; hypertensive encephalopathy, caused by acute capillary congestion and exudation with cerebral edema.
- Kidneys: Failure of circulation due to narrowing of arteries; nephrosclerosis.
- Eyes: Narrowing of arteries; hemorrhages; papilledema.
- Peripheral arteries: Progression of atherosclerotic disease and narrowing of arteries.
- Hypertensive vascular disease: Epistaxis; hematuria; blurring of vision due to retinal changes; weakness or dizziness; angina; dyspnea due to cardiac failure; pain due to dissection of the aorta or leaking aneurysm.
Goals of physicians and coders aren’t identical
2. Know your own motivations, and those of physicians.
Coders should keep in mind as they communicate with physicians that the goals of coders and physicians are not identical. Coders work toward obtaining the best coding documentation and the best reimbursement for the facility, and physicians are concerned about obtaining the most reimbursement for their private practices, Butler says.
"If we ask physicians to focus on how to make the office physician billing work better so that they can get more money, then they will change and adjust behavior faster than when we focus on the hospital," Butler explains. "And we get the information we need either way."
3. Make your goal to understand hypertension and obtain the most accurate documentation possible.
In Butler’s experience, there are vast amounts of inaccurate documentation of hypertension and other diagnoses, and this leads to underbilling.
"In my last 200 chart reviews, I have found as much as $35,000 in incorrect DRG assignments due to inaccurate documentation," Butler recalls. "I focus just on documentation because the coders were fine; they billed what was there."
For example, it’s important not to let target organ damage documentation slip through coding cracks. Butler outlines below some major complications and descriptions that coders should know and look for in what is either included or omitted in physician documentation:
• Hypertensive cardiovascular disease:
— Cardiac complications are the major cause of morbidity and mortality in the hypertensive patient.
— Prevention of cardiovascular disease is the major goal of therapy.
— Left ventricular hypertrophy is found in 2%-20% of chronic hypertensives.
— Left ventricular diastolic dysfunction and congestive heart failure are common in patients with long-standing hypertension.
— Synergistic when combined with coronary artery disease — powerful predictor of subsequent complications.
• Hypertensive cerebrovascular disease:
— Hypertension is a major predisposing cause of stroke, especially intracerebral hemorrhage, but also cerebral infarction.
— More closely correlated with elevated systolic than diastolic elevations.
— Complications are markedly reduced by antihypertensive therapy.
— Preceding hypertension is associated with higher incidence of subsequent dementia — both vascular and Alzheimer’s types.
• Hypertensive renal disease:
— Chronic hypertension causes nephrosclerosis, a common cause of insufficiency leading to failure, and it can be diminished by aggressive pressure control.
— In hypertensive nephropathy with proteinuria, blood pressure should be less than 130/85.
— Hypertension plays an important role in accelerating the progression of other forms of renal disease, including diabetes.
— Angiotensin-converting enzyme inhibitors are particularly effective in preventing the latter complications and appear to prevent the progression of other forms of nephropathy.
• Aortic dissection: Hypertension is a major cause and exacerbating factor in aortic dissection.
• Atherosclerotic complications: Most hypertensives die of complications of atherosclerosis.
Too often, a physicians charts will stop at the word hypertension, leaving the details for coders to obtain through careful detective work.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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