Hypertension is a significant health issue prevalent in the U.S., often leading to serious complications and requiring precise medical documentation for proper management and reimbursement. The transition to a merit-based payment system under MACRA emphasizes the importance of quality care and accurate coding of hypertension, especially when comorbid conditions are present. Accurate coding in ICD-10 is crucial for appropriate treatment and reimbursement, and hypertension affects a substantial portion of the adult population, highlighting the need for regular monitoring and effective management strategies.

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Hypertension is a major health condition
that must be properly managed. It has to
be appropriately documented on medical
claims.

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Recorded as a major health problem (particularly among the elderly) in the
United States, hypertension occurs when your blood pressure increases to
unhealthy levels. An individual’s blood pressure measurement takes into
account how quickly blood is passing through your veins and the amount of
resistance the blood meets while it’s pumping. An article published in the
American Journal of Hypertension (April 2017) reports a rising trend in
hospitalization for hypertensive emergency with reduction in hospital
mortality during the last decade. Patients with acute cardio respiratory
failure, chest pain, stroke, acute chest pain, or aortic dissection were at the
most risk of higher hospital mortality among other complications.
Hypertension is a major contributor for heart disease and other medical
problems. Furthermore, hypertension is often accompanied by co-morbid
conditions such as diabetes mellitus, kidney damage, arteriosclerosis,
obesity, CKD-3, and systolic dysfunction which complicate the treatment for
blood pressure. The problem with this epidemic is very clear, untreated
blood pressure often leads to multiple target organ complications. According
to the research findings from the University of Miami Miller School Of
Medicine, approximately 80 percent of first strokes are a consequence of
preventable risk factors such as hypertension. Since the management of
hypertension is challenging, it is vital to identify and treat blood pressure
appropriately. It is very important for physicians to report this condition
correctly with the right diagnosis codes. Medical coding companies should
ensure correct coding of hypertension to track patients that require
immediate treatment for this chronic medical condition.
Financial Payment System - Transition
MACRA (Medicare Access and CHIP Reauthorization Act) — a Merit-based
Incentive Payment System (MIPS) - primarily links physician reimbursement
to quality of care rather than the volume of services. It is expected that this

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focus on quality will considerably improve efficiency and patient outcomes
while reducing total costs. There are many potential factors that determine
payment under MACRA, but the main theme is how effective and accurate
the provider can be in the diagnosis, management and reporting of patient
care. Whether it is hypertension or any other medical condition, there will be
more potential for that provider to receive higher revenue. This represents a
unique transition from the “fee-for-service reimbursement model” to a more
“quality based Merit-Based" formula. In other words, quality replaces
quantity.
The participating providers will need to report six quality measures
contributing to their overall “Quality score”. Controlling the incidence of
hypertension in patient population is one of the prominent ways to
demonstrate quality. Hypertension is reported as a “high priority measure”
that offers healthcare providers the opportunity to accumulate additional
bonus points (that adds up to their overall score). Since quality is the most
significant contributor to the MIPS Composite Performance Score, the impact
of these bonus points can be financially significant.
Hierarchical Condition Category (HCC) Rating
In simple terms, Hierarchical Condition Category (HCC) value rating is a year
to year estimation of how much the care of an individual should cost, which
in turn may affect reimbursement for that particular service. The more
accurate the HCC value, the better a healthcare practice can ensure
appropriate and fair reimbursement for the care that the patient requires
over time.
There are other benefits of promoting accurate documentation of
hypertension when elevated blood pressure is present with other co-
morbidities. These may mainly include – hypersensitive chronic kidney
disease (stages 1-4) and ESRD and hypersensitive heart disease

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with/without heart failure. Such co-morbidities affect how hypertension as a
diagnosis needs to be accurately coded and also play a role in a provider's
HCC rating. Accurate calculation of HCC rating by the correct coding of
hypertensive disease also ensures a positive payment adjustment from
payers participating in this diagnosis-based risk adjustment model.
Coding for Hypertension
In ICD-10, there is only a single code for primary hypertension without co-
morbid heart or kidney disease-
 I10: Essential (primary) hypertension
However, when hypertension condition is diagnosed in combination with
other conditions such as heart failure, chronic kidney disease (CKD) or heart
disease – the codes essentially change. The accurate coding of hypertensive
diseases may significantly affect HCC values – as this will determine proper
and fair reimbursement from participating payers. The more accurate
diagnosis code selection will lead to more accurate reimbursement rates.
Hypertension and Associated Conditions
If a patient suffering from hypertension is confirmed to have co-morbid
heart and/or kidney disease, it should be reported using ICD-10 codes in the
following manner –
Hypertension and Heart Disease
This category is divided into malignant, benign, and unspecified essential
hypertension with or without heart failure. There are only two codes for the
same condition in ICD-10 such as -
 I11.0 - Hypertensive heart disease with heart failure
 I11.9 - Hypertensive heart disease without heart failure

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Hypertension and Chronic Kidney Disease
If a person suffering from hypertension further develops chronic kidney
disease, ICD-10 will regard that condition as hypertensive chronic kidney
disease. However, if the chronic kidney disease comes first and then the
combination, their codes fall under the secondary hypertension codes. In the
case of hypertensive kidney disease, ICD-10 requires specifying the stage of
the kidney disease and thereby distinguishes stage 5 from end-stage renal
disease by the need of chronic dialysis.
 I12.0 - Hypertensive chronic kidney disease with stage 5 chronic
kidney disease (CKD) or end-stage renal disease (ESRD)
 I12.9 - Hypertensive chronic kidney disease with stage 1 through 4
chronic kidney disease (CKD) or unspecified chronic kidney disease
(CKD)
Both these codes require an additional N18 code to specify the stage of
kidney disease –
 N18.1 - Chronic kidney disease, stage 1
 N18.2 - Chronic kidney disease, stage 2 (mild)
 N18.3 - Chronic kidney disease, stage 3 (moderate)
 N18.4 - Chronic kidney disease, stage 4 (severe)
 N18.5 - Chronic kidney disease, stage 5
 N18.6 - End-stage renal disease
 N18.9 - Chronic kidney disease, unspecified
Hypertension, Heart Disease and Chronic Kidney Disease
The ICD-10 codes for the three-disease combination ((if the patient has all
the 3 conditions - hypertension, heart disease and chronic kidney disease)
are primarily classified according to the degree of chronic kidney disease
rather than the presence or absence of heart failure –

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 I13.0 - Hypertensive heart and chronic kidney disease with heart
failure and with stage 1 through 4 chronic kidney disease, or
unspecified chronic kidney disease
 I13.2 - Hypertensive heart and chronic kidney disease with heart
failure and with stage 5 chronic kidney disease, or end-stage renal
disease
 I13.10 - Hypertensive heart and chronic kidney disease without heart
failure with stage 1 through stage 4 chronic kidney disease, or
unspecified chronic kidney disease
 I13.11 - Hypertensive heart and chronic kidney disease without heart
failure and with stage 5 chronic kidney disease, or end-stage renal
disease
As mentioned above, the two-disease combination codes require additional
codes from the N18 series to specify the different stages of kidney disease.
Tobacco Use or Exposure in Individuals with Hypertensive Diseases
All of the hypertension codes require an additional ICD-10 code if the patient
is a current or former tobacco user. The codes include -
 F17 - Nicotine dependence
 F17.20 - Unspecified
 F17.21 - Cigarettes
 F17.22 - Chewing tobacco
 F17.29 - Other tobacco product
Each of these four categories requires a sixth character –
 0 – uncomplicated
 1 – in remission

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 3 – with withdrawal
 8 – with other specified nicotine-induced disorder
 9 – with unspecified nicotine-induced disorder
On the other hand, if occupational and environmental exposure to tobacco is
influencing the health status of your patient, the following ICD-10 codes
must be used -
 Z57.31- Occupational exposure to environmental tobacco smoke
 Z72.0 - Problems related to lifestyle, tobacco use
 Z77.22 - Exposure to environmental tobacco smoke (includes second-
hand smoke exposure and passive smoking)
 Z87.891- Personal history of nicotine dependence
Secondary Hypertension
In cases of patients having hypertension secondary to other diseases, the
above mentioned ICD-10 codes are not used. The secondary hypertension
codes used in such a situation include -
 I15.0 - Renovascular hypertension
 I15.1 - Hypertension secondary to other renal disorders
 I15.2 - Hypertension secondary to endocrine disorders
 I15.8 - Other secondary hypertension
 I15.9 - Secondary hypertension, unspecified
Reports from the Centers for Disease Control and Prevention (CDC, 2016
statistics) suggest that about 75 million American adults (29%) have high
blood pressure—that is 1 out of every 3 adults. Hypertension, being one of
the chronic health conditions, is a major risk factor for heart disease and
other medical problems. Most people with high blood pressure have no signs
or symptoms, even if blood pressure readings reach dangerously high levels.
Regular blood pressure readings can help you to detect this condition early.

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Treatment for hypertension includes both prescription medication and
healthy lifestyle changes. Healthcare providers can focus on the
management of hypertensive conditions, while their partnering medical
coding service providers ensure accurate reporting of the condition to meet
CMS guidelines.