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Clinical & Coding
Does a pt. that is noncompliant with blood pressure medication and presents to ED with fluid overload, acute on chronic diastolic HF and SBP of 230 given IV antihyperstesive (labetalol and hydralazine) code as hypertensive emergency or urgency?
If a patient has HTN and has documentation in the MR HTN and has CHF you can use the code for Hypertensive Heart as your PDX and take the mcc of A/C Diastolic HF. If HTN emergency or urgency has not been documented by the attending you will need to query.
CHF and HTN was documented along with hypertensive urgency. Question is should hypertensive emergency qualify for a person coming in with SBP of 230 and receiving IV antihypertensive meds due to noncompliance?
The medical situation would be the same whether compliant or not. Noncompliance would be coded.
I was under the impression that hypertensive emergency was defined, based on the presence of symptomology as well as the elevated blood pressure reading. There has to be documentation of headache, visual disturbance, numbness/tingling, etc as well as treatment with IV anti hypertensive medications.