Hypertension Column 1 – type of hypertensive condition Columns 2-4 – Malignant, Benign, Unspecified Hypertensive Heart Disease – secondary to sustained systemic hypertension Types of hypertension having their own codes: essential or NOS with heart disease kidney disease and chronic kidney disease heart and chronic kidney disease cerebrovascular disease retinopathy secondary transient controlled/uncontrolled elevated blood pressure
Diagnostic Tools Diagnostic uncertainty leads to multiple tests EKG, MRI, CT scan, Blood tests, biopsies Some diagnoses need specific site codes example: Acute Myocardial infarction – of ? Anterior wall, inferolateral wall, posterior wall, etc. Tests, surgeries --- all need procedure codes to match the type of diagnosis code(s)
Complications Pregnancy Childbirth Ectopic Molar Abortion (spontaneous, induced, failed) Related to pregnancy Childbirth Labor related (early onset) Normal delivery – trauma to perineum or vulva cord defects stillbirth pelvic infection breech obstruction C-section
Skin Issues Depth Debridement (procedure – excisional/nonexcisional) Color Foreign object or substance as cause