Q: “How do you make a distinction between controlled and uncontrolled hypertension?”
A: The simple answer to this is your physicians or the documentation that you’re reviewing should clearly indicate whether the patient is hypertension is controlled or uncontrolled. Typically, we assume and we’re taught to assume from a coding perspective that the hypertension is controlled, unless the provider says something to indicate otherwise. Just like when we talk about other topics, like, fractures, we assume that it’s a closed fracture unless they say it’s an open fracture.
With hypertension, we assume that it is controlled unless they give us some sort of indication to say, “This is not controlled.” And that could be lots of different things, they could be changing dosages, they could simply state uncontrolled, not well-controlled. That is a piece of documentation that we’re frequently missing. As we continue to do physician education, that’s a big piece to push, especially as we move to value-based payment and away from the fee-for- service environment and more towards value based.
More Information about coding hypertension controlled vs uncontrolled:
Coding for Hypertension - For the Record http://www.fortherecordmag.com/archiv… Apr 23, 2012 - Do not assign a code for benign or malignant hypertension unless it is … controlled, uncontrolled, and primary would be coded here unless it …
Understanding How \u0026 When to Code Hypertension health-information.advanceweb.com/…/Understanding-How-When-to-C… Mar 29, 2013 - Unfortunately, in ICD-9-CM, there is not a specific code for either controlled or uncontrolled hypertension, so the appropriate code from …
ICD-10-CM Full Course Online Training by Certification Coaching Org (CCO) http://go.cco.us/icd-10-cm-full-course The class is awesome, great teacher,and actually fun. Thank you so much for getting my …
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