I50.32 Chronic diastolic (congestive) heart failure.I11.0 Hypertensive heart disease with heart failure.There is 2+ pitting edema in both ankles.Īssessment: Hypertension – poorly controlled chronic diastolic congestive heart failure Social history shows her to be a former smoker. Currently she is on Lasix, Lanoxin and Atenolol. Recent EKG demonstrates findings consistent with cardiomegaly, but no recent change since a prior EKG. She has been having ongoing shortness of breath and orthopnea. Subjective: 75-year-old female is seen for follow up for chronic hypertensive heart disease.
Chord pickout 3.0 serial code#
An instructional note provided for categories I10-I15 states to use an additional code to identify exposure to environmental tobacco smoke (Z77.22), history of tobacco use (Z87.891), occupational exposure to environmental tobacco smoke (Z57.31), tobacco dependence (F17-) or tobacco use (Z72.0). Hypertension, whether uncontrolled, untreated or not responding to current medication, is assigned code I10. F17.210 Dependence, nicotine, cigarette, uncomplicated.I10 Hypertension (essential, benign, primary).Diagnosis is benign hypertension without good control, nicotine dependence. Physician adjusts medications, counsels on smoking. He continues to smoke two packs of cigarettes per day, and does not want to stop. When both hypertension and heart disease are stated in documentation, but the causal relationship is not stated or implied, each code is reported separately and the combination code is not used.Įxample: A 67-year-old patient is seen for benign hypertension. I50.31 Acute diastolic (congestive) heart failure.I13.2 Hypertensive heart and renal disease with heart failure due to hypertension with end stage renal disease.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.