The instruction for coding hypertensive heart disease in the 2018 ICD-10-CM Official Guidelines for Reporting has many wondering: “are we supposed to assume a disease has a causal relationship when it has not been documented by the physician?” Like it or not, the guideline tells us yes. What does that mean for coding staff who have been conditioned to ‘code to the highest level of specificity’?
Most physicians and mid-levels don’t typically chart that Coronary Artery Disease and HTN are related unless the patient is admitted with Acute Coronary Syndrome (ACS) and in concurrent hypertensive crisis. To most clinical staff, hypertensive heart disease means that there is evidence of end organ involvement from HTN; for example, chamber enlargement, HF, LVH, strain. Have you ever seen physicians or mid-level providers chart this way? The coding language and clinical language differs.
Join cardiology coding expert Terry Fletcher during this 60-minute educational webcast as she clears up the confusion surrounding the new “default” instruction, and shows you how to handle situations when unclear documentation can cause coder confusion.
Why This is Relevant:
ICD-10-CM has certain instructions throughout its coding guidelines that will instruct a coder to “presume” causal relationships between certain conditions when heart disease is also recognized as a condition for the patient, even without the physician specifically linking these conditions in their documentation. With reimbursements tied specifically to diagnoses, and Hierarchical Condition Category (HCCs) weighing in on overall risk of a patient, it is important for coder to use caution when abiding by these new rules of assumptive coding.
During this unprecedented webcast conducted by nationally-recognized coding authority Terry Fletcher, you will…
- Learn how to code heart disease with hypertension
- Understand the link between heart disease and hypertension
- Explore the coding options that might have a causal relationship between heart disease and kidney disease
- Learn whether or not rheumatic valve disease has an assumption in its coding instruction. Ms. Fletcher will clear up the confusion on this subject
- Learn how to code diabetes mellitus in the absence of specific details from your physician's documentation
- Discover what takes precedence in ICD-10-CM learning—the ICD-10-CM Chapter directives? Or the ICD-10-CM official guidelines for coding and reporting? The answer to this question is complex. But we've got you covered!