Coding, Classification & Reimbursement

Hypertension due to endocrine disorder and other Shenanigans

  • 1.  Hypertension due to endocrine disorder and other Shenanigans

    Posted 8 days ago
    ​​Hello Everyone,

    I'm reviewing a Texas SNF record.

    The patient's primary dx was changed from G30.9 Alzheimer's Disease, unspecified to History of Falls, because the patient had a recent fall (no injuries...no need t for a hospital visit) <  ------- I shook my head when I saw the change in primary dx. G30.9 was incorrect, too. The 03/02/19 H&P clearly states that the patient developed  short-term memory loss/dementia 5 years ago and was brought to the facility, because her husband was no longer able to care for her at home.

    I think G30.1 Alzheimer's disease with late onset would be a more appropriate dx (What do you think?)

    These other dx are listed on the H&P and physician progress notes: Questions are highlighted
    • Type II DM, with other specified complication: Hyperglycemia was not documented. The orders says that there are no complications....that contradicts what's written on the progress notes.The patient is on oral anti-diabetic medication and insulin.
    • Hypertension due to endocrine disorder: Review of Systems: Endocrine: Hypothyroidism and DM   < -----Does this mean that I don't code the HTN with CKD....they are unrelated?
    • Chronic Kidney Disease, Stage III
    • Major Depressive Disorder (Documented on the attending physician's progress notes, but not on Psych notes.) (Psych only documented about the Alzheimer's, Age Related Cognitive Decline, General Anxiety, Adjustment Disorder) Should the Major Depressive Disorder be coded?
    • Anemia
    • Seizure Disorder
    • Essential Tremor
    • History of Falls


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    Regards,
    Katherine Valeri, RHIT

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  • 2.  RE: Hypertension due to endocrine disorder and other Shenanigans

    Posted 7 days ago
    Edited by Andrea Wong 7 days ago
    Thoughts regarding the codes in question:

    With regards to assigning a code for G30.9 Alzheimers Disease (unspecified), coding convention I.A. 19 " The assignment of a diagnosis code is based on the providers diagnostic statement that the condition exists. The provider's statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis." Coders should only assign codes based on physician and provider statements. Never assume anything even if the patient was diagnosed recently with Alzheimers. Dementia codes are always sequenced secondary to Alzheimers, as manifestation codes. The index displays these secondary codes in brackets F02.80 (without behavioral disturbance) or F02.81 (with behavioral disturbance.)

    Since the husband was unable to care for the patient at home, I would additionally code Z74.2 – Need for assistance at home and no other household member able to render care.

    Diabetes Type 2
    -  would not code hyperglycemia if this was not documented by the physician. LTU of insulin would be coded additionally. In the tabular, Category Z79- includes " long term (current) drug use for prophylactic purposes." Coding guidelines in chapter 21 state that Z79 codes are also used for "long term treatment of the condition." The patient doesn't have to have hyperglycemia to be taking medications. Please take note that the sub-terms under Diabetes are considered synonymous with hyperglycemia are: "out of control, poorly controlled." If the physician uses the term "uncontrolled," further clarification is needed to interpret the meaning.
    - I'd code your encounter as E11.9, Z79.4
    - Note that Z79.84 is not coded when both oral and insulin are used, as there is a hierarachy per "Coding Guideline. I.C.4.a.3. Diabetes mellitus and the use of insulin and oral hypoglycemics" which states that if the patient is treated with both oral and insulin, only the code for the long-term use of insulin should be assigned.

    Regarding Hypertension due to endocrine disorder who has CKD stage 3, The codes would be assigned as follows:

    I15. 2 – Hypertension secondary to endocrine disorders.

    -There is a “code also underlying condition” note below the I15- category. Sequencing of the underlying condition and I15.2 will depend on the circumstances of the encounter. “Code also” does not provide sequencing direction when it comes to matters of the Primary/Principal diagnosis.
    -HTN and CKD would not be presumed because the 2 conditions were stated to not be related per Coding Conventions applying the term "With." In addition I12-category has an exclude 1 note: "secondary hypertension (I15-)" so they are not coded together unless explicitly documented to be dually related, but in our case, the condition is coded to I15.2. Coding guidelines state: "For hypertension and conditions not specifically linked by relational terms, ‘with, associated with or due to’ in the classification, provider documentation must link the conditions in order to code them as related.
    -In addition, Optum 2019 ICD-10-CM codebook provides an example of the guideline on page 633 that when a patient has hypertension secondary to Primary hyperparathyroidism and CKD 4, it would be coded as N18.4, I10, E21.0. In that example, the patient was admitted for the CKD, so it was sequenced first.

    E05.90 – Thyrotoxicosis, unspecified without thyrotoxic crisis or storm for (Hyperthyroidism)
    -There is a “code also underlying condition” note below the I15- category.
    -Although there was not a specific endocrine disorder stated by the physician, the coder can still code the case correctly without further specification needed by the physician because a general cause and effect relationship was sufficient information to code. A few of the commonly known endocrine disorders that can cause hypertension are: Hyperthyroidism, Primary Hyperparathyroidism, aldosteronism, Cushings Syndrome, pheochromcytoma, and acromegaly, etc.

    N18.3 – CKD stage 3 is still assigned.

    D63.1 – Anemia in Chronic kidney disease.
    -       Anemia and CKD are presumed. Coding Conventions state that: "the word 'with' or 'in' should be interpreted to mean 'associated with' or 'due to' when it appears in a code title, the Alphabetical index (either under a main term or subterm), or an instructional note in the Tabular list. The classification presumes a causal relationship between the two conditions linked by theses terms in the Alphabetical List or Tabular list. 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 or when another guideline exists…"
    -       Index: Anemia > in > chronic kidney disease > D63.1
    -       Reference: ICD-10-CM and ICD-10-PCS Coding Handbook 2018, by Nelly Chisen, Page 28.

    F32.9 – Major depressive disorder, single episode, unspecified.
    -       Tabular: Although the 5th character designation is coded by episode and severity, F32.9 has terms that include "Depression NOS," so would be categorized under this code if it has a bearing on the stay. The fact that the patient was monitored in progress notes over several days for depression would justify coding it, and if the patient's receiving medications to treat it. If the physician only noted it as a history, probably wouldn't code it, unless stated to be "in remission" by the physician.
    -       UHDDS: "Code diagnosis that require clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, or increasing nursing care and/or monitoring. Diagnoses that relate to an earlier episode that have no bearing on the current hospital stay are excluded. UHDDS definitions apply to long-term care." If you do not think treatment was directed toward the condition, you can use a history code.


    Hope this clarifies any confusion. Happy Coding!

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    Andrea Wong
    Coder
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  • 3.  RE: Hypertension due to endocrine disorder and other Shenanigans

    Posted 3 days ago
    ​Thank you Andrea

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    Katherine Valeri, RHIT
    Medical Records Consultant
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  • 4.  RE: Hypertension due to endocrine disorder and other Shenanigans

    Posted 7 days ago
    This message was sent securely using Zix®

    Katherine, does the medical record state Alzheimer's disease with late onset? If it don't specifically state "late onset" you can only code the unspecified which would be G30.9, F02.80. You are correct that Hypertension due to endocrine disorder means you do not link HTN with CKD unless they have both which is possible but don't assume that, based on what you shared your code would be I15.2, E03.9 (I believe you can code those two in any order but I would list the I15.2 first then the E03.9). You would also code the depression. Anemia would be coded as D63.1 per the coding guidelines....we assume anemia and CKD and linked unless the physician specifically states they are not. I also would code the seizure and tremors & falls.

     

    G30.9......not sure if you would just code F03.90, does it state Alzheimer's or just dementia?

    F02.80......don't code this if you are coding F03.90 ��

    E11.9

    I15.2

    E03.9

    N18.3

    D63.1

    F32.9

    G40.909

    G25.0

    Z79.4

    Z91.81

     

    Does the record mention Alzheimer's? Because you just list that the H&P clearly states that the patient developed short-term memory loss/dementia 5 years ago. Based on that (if that is all you got) the code would be F03.90.

     

    Brenda Mohs, RHIT

    Home Health & LTC Medical Coder

    Essentia Health

    Brenda.Mohs@Essentia Health.org

     




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  • 5.  RE: Hypertension due to endocrine disorder and other Shenanigans

    Posted 3 days ago
    ​Thank you Brenda

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    Katherine Valeri, RHIT
    Medical Records Consultant
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