Health Information Management

Q&A: Coding when diagnosis documentation includes 'and'

JustCoding News: Inpatient, June 23, 2010

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QUESTION: According to inpatient coding guidelines, when we see a diagnosis followed by “due to,” “with” or similar terminology (e.g., hypertension with congestive heart failure), we link the diagnoses (e.g., hypertensive heart failure). Does “and” qualify as similar terminology?

ANSWER: When a physician diagnoses a patient with both hypertension and heart disease, you must carefully read the notes to determine whether the documentation clearly indicates a causal relationship between the two conditions.

The terms “and” and “with” most often indicate the presence of both issues, but no connection between the two. In other words, in your example above, there is no definitive statement that the hypertension caused the heart disease. Therefore, you should code each of these diagnoses separately. For the case you described, you would report ICD-9-CM code 401.1 (hypertension, benign) and ICD-9-CM code 428.0 (congestive heart failure, unspecified).

The ICD-9-CM Official Coding Guidelines for Coding and Reporting, Section 1, c.7.a.2, Hypertension with heart disease states, “The same heart conditions (425.8, 429.0-429.3, 429.8, 429.9) with hypertension, but without a stated causal relationship, are coded separately.”

When documentation includes a phrase such as “due to,” this clearly reports a causal relationship. For example, if documentation states, “heart disease due to hypertension,” you would report one combination code from category 402 (hypertensive heart disease).

However, hypertension with renal disease has a different rule. In these cases, you may assume the causal relationship between hypertension and kidney disease. So you may always assign the appropriate code from category 403 (hypertensive chronic kidney disease).

Editor’s note: Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee, WI. E-mail her at ssafian@embarqmail.com.

This answer was provided based on limited information submitted to JustCoding.com. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.



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