HTN, ckd, chf

According to the 2017 guidelines - linkage between HTN and "heart involvement" and kidney involvement ( already assumed) will not require a link.http: //www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf

So if I understand it correctly-every patient with HTN, CKD and acute CHF will automatically be MCC'd  I13.0 or I132...

This is odd to me because  to query for the term hypertensive heart disease certain clinical evidence, historically needed to be present, like LVH.  Docs don't always agree now that the hypertension causes the heart disease.

Chapter 9 in the 2017 coding guideline... states an assumption of htn, heart disease and ckd even if the term with is not stated...

The classification presumes a causal relationship between hypertension and heart involvement and between hypertension and kidney involvement, as the two conditions are linked by the term "with" in the Alphabetic Index. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For hypertension and conditions not specifically linked by relational terms such as "with," "associated with" or "due to" in the classification, provider documentation must link the conditions in order to code them as related. ((( The second statement should probably read  for htn and  OTHER conditions  ... provider must be link)))) 1) Hypertension with Heart Disease Hypertension with heart conditions classified to I50.- or I51.4-I51.9, are assigned to a code from category I11, Hypertensive heart disease. Use an additional code from category I50, Heart failure, to identify the type of heart failure in those patients with heart failure. This like the preserved HFp EF coding to diastolic heart failure, is odd. I have seen "Acute HFpEF" written  and the echo states " normal diastolic dysfunction- but we are coding acute diastolic CHF. --- all this being said...  would this ever come in to play if CHF weren't ACUTE and POA? because it would just be a secondary condition ... right? do you think it's because doctors lack of linking of htn to relationship to heart disease is not capturing a relationship... CMS thinks should be established? even if the docs would not feel that they would make the assumption, yet CMS will?

Comments

  • You may need to refer back to the coding tabular list. "hypertension, with...Heart involvement (conditions in I51.4-I51.9)" does not included CHF (I50 codes). There is only a assumed link to those codes I51.4-I15.9. Where it gets tricky is when you do have "Hypertensive heart disease (any of the conditions in I51.4-I51.9)" with heart failure. That is an assumed link, not "Hypertension" alone and Heart failure. Or at least this is the way I see it. I'm hoping for further clarification on this.
  •  IN the 2017 it seems to include I50...?If hypertensive heart disease written it seems clear even with todays guidelines. But my understanding is this changes come October ( I'm assuming 2017 guidelines go into effect October 1, 2016) ?__
    Hypertension with Heart Disease

    Hypertension with heart conditions classified to I50.- or I51.4-I51.9, are assigned to a code from category I11, Hypertensive heart disease. Use an additional code from category I50, Heart failure, to identify the type of heart failure in those patients with heart failure.

    ICD-10-CM Official Guidelines for Coding and Reporting FY 2017 Page 43 of 114

    The same heart conditions (I50.-, I51.4-I51.9) with hypertension are coded separately if the provider has specifically documented a different cause. Sequence according to the circumstances of the admission/encounter

  • I see where the 2017 Coding guidelines do list I50.-.  However, when I went to the CMS.gov site and reviewed the 2017 ICD-10 CM Index, I50.- was not included. I think there is clarification needed. Very interesting. Thanks for bringing this up.

    Hypertension, hypertensive (accelerated) (benign) (essential) (idiopathic) (malignant) (systemic) I10 - with
    - - heart involvement (conditions in I51.4- I51.9 due to hypertension) -see Hypertension, heart
    - - kidney involvement -see Hypertension, kidney

    - heart (disease) (conditions in I51.4-I51.9 due to hypertension) I11.9
    - - with
    - - - heart failure (congestive) I11.0

    - - - kidney disease (chronic) -see Hypertension, cardiorenal- - with

    - - - heart failure (congestive) I11.0
    - - - kidney disease (chronic) -see Hypertension, cardiorenal

  • Thanks, I see exactly what you are talking about. Look forward to more input/clarification.
  • Our facility (CDI team) is having the same struggle with this new Oct 2017 guideline.  If it is an accurate interpretation that there is an automatic link between CKD, CHF, and HTN then when would you ever code CHF exacerbation as a principal diagnosis since most patients have HTN and/or CKD along with CHF?  We have a scenario where the patient presented with CHF exacerbation and hypotenson likely due to dietary indiscretion- BP meds were held and only on the discharge summary the provider documented 'cardiorenal syndrome'.  It seems the true nature of the visit was the CHF exacerbation and hypotension..but with the new changes our coders feel it is more accurate to code the combination code I13.10 due to the dc summary documentation of 'cardiorenal syndrome'.  
  • We are struggling with these guidelines as well. We have sent off information to AHA for further information and hoping a coding clinic will further clear up the confusion.
  • This is a problem for me as well.  I have a patient with a history of hypertension. Came in with acute systolic heart failure and has CKD.  The patient is hypertensive.  Do I query for hypertension as an active problem??  Then my acute systolic CHF can be my MCC.  Not certain that seems correct?

  • Gtstayrook... I don't think that is even necessary. the htn will be coded if they have the history, assuming  they are on meds for htn ( but maybe even if they are not), and the link will be automatic.

    My understanding is that if the patient comes in with acute chf or acute kidney injury when they have ESRD...  ( htn hx) an I13___ code will be automatic and the acute specified chf or the ESRD will be the MCC.

    For me the potential query opportunity would be, any time ACUTE __CHF, is present, look for the other two conditions. if they are there you should be in I13__ if not... is there evidence of those chronic conditions that are not diagnosed or not in the current record?

    Often CKD 2 is not diagnosed, GFR 60-90. That GFR value should be not taken exclusively in an exacerbated state, but if evidence suggest that the GFR lives below 90  ( not all hospitals lab values specify values greater than 60- but if your's does, you can look at that), then it is reasonable to ask and get that chronic relevant condition in the chart. ... Same with HTN, I have had to look hard sometimes, and really it has just fallen out of their history but they are on lots of cardiac medications, have chf, and ckd... the likelihood they DON'T have HTN is pretty low.

    I think it's a new area we will start hearing more and more opinions on. I'd definitely try to discuss it with your cdi and coding teams, if you have a confident, collaborative, supportive team you may find this a great query opportunity. As always if a consultant hasn't spelled it out and sold it to your facility, some people don't have confidence in their own clinical judgement, but it will evolve I'm sure. 


  • Thanks annnd2009 for the input.  I wasn't certain how to handle the hypertension.  I am looking at this as opportunity as well.


  • Danielle have you received a response from Coding Clinic yet?

    I hope they publish their advice on this. I was going to submit the same question but searched this forum and saw that you had submitted already.

    Cathy Seluke
    We are struggling with these guidelines as well. We have sent off information to AHA for further information and hoping a coding clinic will further clear up the confusion.

  • Many are questioning the intent of these guidelines given they represent quite a departure from previous advice and published Guidelines.  However,  for now at least,  the relationship is 'assumed'.


    Paul Evans

  • Many are questioning the intent of these guidelines given they represent quite a departure from previous advice and published Guidelines.  However,  for now at least,  the relationship is 'assumed'.


    Paul Evans

    Paul-did you see my post in the new thread on this subject? I would like to have your opinion on the principal diagnosis question.

    Cathy
  • Hi, Cathy - I am 'lost' in the thread, and don't see it. 

    Do you wan to call me?  415.412.9421


    Paul

  • My coders will not capture the combination code for hypertension heart disease/chf/ckd  as a principle unless a link is documented between the hypertensive heart disease and the chf.  They say the tabular list is conflicting with the new coding guidelines and they are going with the tabular list until they receive further clarification from a coding clinic.  I thought if I got the physician to state hypertensive heart disease and the patient had chf.  That we could use the combination code.  They are telling me they need linked together?  Thoughts?
  • Although controversial, the Guidelines now assume a certain linkage between HTN, CKD AND CHF.   Further, if the MD also links the hypertension to the CHF, the combination codes are used.    Have you searched this site for articles and guidance for this topic as I recall various members have offered very helpful advice w/ citations.


    Paul Evans, RHIA, CCDS

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