ICD-10 Coding for Uncontrolled Hypertension(I10, I16.1)
Complete ICD-10-CM coding and documentation guide for Uncontrolled Hypertension. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Uncontrolled Hypertension
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| I10 | Essential (primary) hypertension | Use when documenting essential hypertension that is uncontrolled, supported by clinical evidence. |
|
| I16.1 | Hypertensive emergency | Use when documenting a hypertensive crisis with acute complications. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for uncontrolled hypertension
Essential facts and insights about Uncontrolled Hypertension
Primary ICD-10-CM Codes for uncontrolled hypertension
Decision Criteria
clinical Criteria
- BP readings consistently ≥140/90 despite treatment
documentation Criteria
- Explicit mention of 'uncontrolled hypertension' in the medical record
Applicable To
- Uncontrolled essential hypertension
Excludes
- Secondary hypertension (I15.-)
Clinical Validation Requirements
- BP readings ≥140/90 on at least two separate occasions
- Documentation of treatment adjustments or medication changes
Code-Specific Risks
- Assuming control status without explicit documentation
Coding Notes
- Ensure documentation explicitly states 'uncontrolled' or provides evidence of treatment changes.
I16.1 - Hypertensive emergency
Use when documenting a hypertensive crisis with acute complications.
Applicable To
- Malignant hypertension with end-organ damage
Excludes
- Hypertensive urgency (I16.0)
Clinical Validation Requirements
- Evidence of acute end-organ damage (e.g., retinal hemorrhages, acute renal failure)
Coding Notes
Ensure documentation of specific organ damage to support the use of this code.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Other long term (current) drug therapy
Z79.899Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Uncontrolled Hypertension to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I10.
Impact
Clinical: Inaccurate representation of patient's condition., Regulatory: Potential audit findings for non-compliance., Financial: Missed opportunities for appropriate reimbursement.
Mitigation Strategy
Educate providers on documentation requirements., Implement EHR prompts for uncontrolled hypertension.
Impact
Reimbursement: Potential underpayment due to inaccurate risk adjustment., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Query the provider to confirm and document 'uncontrolled hypertension'.
Impact
Inadequate documentation of control status for hypertension.
Mitigation Strategy
Regular training and audits to ensure compliance with documentation standards.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Uncontrolled Hypertension, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Uncontrolled Hypertension
Use these documentation templates to ensure complete and accurate documentation for Uncontrolled Hypertension. These templates include all required elements for proper coding and billing.
Chronic Uncontrolled Hypertension Management
Specialty: Internal MedicineRequired Elements
- BP readings over multiple visits
- Medication adjustments
- Assessment of target organ damage
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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