Coding According to Local Medical Review Policy. (Featured CME Topic: Hypertension).Local medical review policies potentially differ from state to state. A procedure that is medically reasonable and necessary in one state may not be in another state. Payment denials that are code driven are often avoidable by understanding and addressing medical necessity coding concerns and complying with Local Medical Review Policies (LMRPs). The Centers for Medicare and Medicaid Services The Centers for Medicare and Medicaid Services (CMS), previously known as the Health Care Financing Administration (HCFA), is a federal agency within the United States Department of Health and Human Services (DHHS) that administers the Medicare program and (CMS (1) See content management system and color management system. (2) (Conversational Monitor System) Software that provides interactive communications for IBM's VM operating system. ) (formerly known as the Health Care Financing Administration Health Care Financing Administration, n.pr department in the U.S. agency of Health and Human Services responsible for the oversight of the Medicaid and Medicare benefit programs, including guidelines, payment, and coverage policies. ), the federal agency responsible for administration of the Medicare Medicare, national health insurance program in the United States for persons aged 65 and over and the disabled. It was established in 1965 with passage of the Social Security Amendments and is now run by the Centers for Medicare and Medicaid Services. , Medicaid Medicaid, national health insurance program in the United States for low-income persons; established in 1965 with passage of the Social Security Amendments and now run by the Centers for Medicare and Medicaid Services. , and State Children's Health Children's Health Definition Children's health encompasses the physical, mental, emotional, and social well-being of children from infancy through adolescence. Insurance programs, contracts with certain organizations to assist in the administration of the Medicare program (Medicare contractors). Medicare contractors are required to develop and disseminate dis·sem·i·nate v. dis·sem·i·nat·ed, dis·sem·i·nat·ing, dis·sem·i·nates v.tr. 1. To scatter widely, as in sowing seed. 2. LMRPs. The use of local medical review policy helps avoid situations in which claims are paid or denied without a full understanding of the reasoning behind the decision. Local medical review policies are developed to assist providers, physicians, and suppliers in submitting correct claims for payment. Local policies outline when and under what conditions a service, item, or supply is considered medically reasonable and necessary, as well as the methods contractors will use to review claims. The CMS requires that local policies be consistent with national guidelines guidelines, n.pl a set of standards, criteria, or specifications to be used or followed in the performance of certain tasks. and be developed with scientific evidence and clinical practice. While local policies must be consistent with national guidelines, they can be and often are more detailed or specific. Each state having its own Medicare contractor contractor n. 1) a person or entity that enters into a contract. 2) commonly, a person or entity that agrees to construct a building or to provide or install specialized portions of the construction. results in each state having its own LMRP LMRP Local Medical Review Policy LMRP Lower Marine Riser Package (ocean drilling) . This means that what is considered medically reasonable and necessary in one state may not be in another state. For example, in Tennessee Tennessee, state, United States Tennessee (tĕn`əsē', tĕn'əsē`), state in the south-central United States. a urinalysis urinalysis (y  r'ənăl`ĭsĭs), clinical examination of urine for the purpose of medical diagnosis. (CPT CPTSee: Carriage Paid To codes 81001-81005, 81015) is a covered procedure with a diagnosis of essential hypertension essential hypertension n. Hypertension without known cause or preexisting renal disease. essential hypertension (ICD-9-CM ICD-9-CM International Classification of Disease, 9th edition, Clinical Modification A standardized classification of disease, injuries, and causes of death, by etiology and anatomic localization and codified into a 6-digit number, which allows code 401.0-401.9), hypertensive heart disease Hypertensive heart disease High blood pressure resulting in a disease of the heart. Mentioned in: Myocarditis hypertensive heart disease (402.00-402.91), hypertensive hypertensive /hy·per·ten·sive/ (-ten´siv) 1. characterized by increased tension or pressure. 2. an agent that causes hypertension. 3. a person with hypertension. renal disease Renal disease Kidney disease. Mentioned in: Glycogen Storage Diseases hypertension High blood pressure Cardiovascular disease An abnormal ↑ systemic arterial pressure, corresponding to a systolic BP of > 160 mm Hg (403.0-403.91), hypertensive heart and renal disease (404.0-404.93), or secondary hypertension Noun 1. secondary hypertension - hypertension that is secondary to another disease high blood pressure, hypertension - a common disorder in which blood pressure remains abnormally high (a reading of 140/90 mm Hg or greater) (405.01-405.99). In Alabama Alabama, indigenous people of North America Alabama (ăləbăm`ə), indigenous people of North America whose language belongs to the Muskogean branch of the Hokan-Siouan linguistic stock (see Native American languages). , on the other hand, prior to October October: see month. 2001, the only hypertension hypertension or high blood pressure, elevated blood pressure resulting from an increase in the amount of blood pumped by the heart or from increased resistance to the flow of blood through the small arterial blood vessels (arterioles). codes considered appropriate for coverage of urinalysis were 403.00-403.01 (hypertension with renal renal /re·nal/ (re´n'l) pertaining to the kidney. re·nal adj. Of or in the region of the kidneys. Renal Relating to the kidney. involvement) and 405.01-405.99 (secondary hypertension). In patients having essential hypertension. and hypertensive heart disease, urinalysis was not considered medically reasonable and necessary. While Arkansas' LMRP provides coverage, of urinalysis for patients having hypertension, the added cav eat denies coverage if urinalysis is performed at a frequency greater than is necessary for the reasonable medical management of the patient's condition. Understanding payment changes and denial denial, in psychology, an ego defense mechanism that operates unconsciously to resolve emotional conflict, and to allay anxiety by refusing to perceive the more unpleasant aspects of external reality. trends is one way to safeguard against arbitrary Irrational; capricious. The term arbitrary describes a course of action or a decision that is not based on reason or judgment but on personal will or discretion without regard to rules or standards. specificity in local medical polices. The best way is to ensure that accurate information is obtained and documented in the patient record; this will additionally allow for more accurate coding of testing diagnoses. It is critical to equitable equitable adj. 1) just, based on fairness and not legal technicalities. 2) refers to positive remedies (orders to do something, not money damages) employed by the courts to solve disputes or give relief. (See: equity) EQUITABLE. reimbursement Reimbursement Payment made to someone for out-of-pocket expenses has incurred. to provide proper documentation, in the form of appropriate and complete ICD-9-CM codes, to support the use of a particular procedure. Required documentation elements are spelled out in an LMRP. Knowledge of the specificity of diagnosis codes can be helpful to remind the physician to state what is known about the patient. The accompanying ac·com·pa·ny v. ac·com·pa·nied, ac·com·pa·ny·ing, ac·com·pa·nies v.tr. 1. To be or go with as a companion. 2. Table of hypertension codes is used to illustrate the specificity available for coding. Coding is required for reimbursement, but it is also used as a means of gathering information for statistical purposes. The coder has many code choices for hypertension. Unless the physician reflects, through documentation, the intuitive process used to make the diagnosis, coders are left to code from incomplete record documentation.
2002 Hypertension Codes
Hypertension, hypertensive Malignant Benign
(arterial) (arteriolar) (crisis)
(degeneration) (disease) (essential)
(fluctuating) (idiopathic) (intermittent)
(labile) (low renin) (orthostatic)
(paraxysmal) (primary) (systematic)
(uncontrolled) (vascular) 401.0 401.1
with
heart involvement (conditions classifiable
to 425.8, 428, 429.0-429.3, 429.8, 429.9
due to hypertension) see also Hypertension,
heart) 402.00 402.10
with kidney involvement--see Hypertension,
cardiorenal renal involvement (only
conditions classifiable to 585, 586, 587)
(excluded conditions classifiable to 584)
(see also Hypertension, kidney) 403.00 403.10
with heart involvement--see Hypertension,
cardiorenal failure (and sclerosis) (see
also Hypertension, kidney) 403.01 403.11
sclersois without failure (see also
Hypertension, kidney) 403.00 403.10
accelerated (see also Hypertension, by type,
malignant) 401.0 --
antepartum--see Hypertension complicating
pregnancy, childbirth, or the puerperium
cardiorenal (disease) 404.00 404.10
with
heart failure (congestive) 404.01 404.11
and renal failure 404.03 404.13
renal failure 404.02 404.12
and heart failure (congestive) 404.03 404.13
cardiovascular disease (arteriosclerotic) 402.00 402.10
(sclerotic)
with
heart failure (congestive) 402.01 402.11
renal involvement (conditions classifiable
to 403) (see also Hypertension,
cardiorenal) 404.00 404.10
cardiovascular renal disease (sclerosis)
(see also Hypertension cardiorenal) 404.00 404.10
cerebrovascular renal (disease NEC 437.2 437.2
complicating pregnancy, childbirth, or the
puerperium 642.2 642.0
with
albuminuria (and edema) mild -- --
severe -- --
edema (mild) -- --
severe -- --
heart disease 642.2 642.2
and renal disease 642.2 642.2
renal disease 642.2 642.2
and heart disease 642.2 642.2
chronic 642.2 642.0
with pre-eclampsia or eclampsia 642.7 642.7
fetus or newborn 760.0 760.0
essential -- 642.0
with pre-eclampsia or eclampsia -- 642.7
fetus or newborn 760.0 760.0
fetus or newborn 760.0 760.0
gestational -- --
pre-existing 642.2 642.0
with pre-ecalmpsia or eclampsia 642.7 642.7
fetus or newborn 760.0 760.0
secondary to renal disease 642.1 642.1
with pre-ecalmpsia or eclampsia 642.7 642.7
fetus or newborn 760.0 760.0
transient -- --
due to
aldosternoism, primary 405.09 405.19
brain tumor 405.09 405.19
bulbar poliomyelitis 405.09 405.19
calculus
kidney 405.09 405.19
ureter 405.09 405.19
coarctation, aorta 405.09 405.19
Cushing's disease 405.09 405.19
glomerulosclerosis (see also Hypertension, 403.00 403.10
kidney)
periarteritis nodosa 405.09 405.19
pheochromocytoma 405.09 405.19
polycystic kidney(s) 405.09 405.19
polycythemia 405.09 405.19
porphyria 405.09 405.19
pyelonephritis 405.19 405.19
renal (artery)
aneurysm 405.01 405.11
anomaly 405.01 405.11
embolism 405.01 405.11
fibromuscular hyperplasia 405.01 405.11
occlusion 405.01 405.11
stenosis 405.01 405.11
thrombosis 405.01 405.11
encephalopathy 437.2 437.2
gestational (transient) NEC -- --
Goldblatt's 440.1 440.1
heart (disease) (conditions classifiable to
425.8, 428, 429.0-429.3, 429.8, 429.9 due
to hypertension) 402.00 402.10
with
heart failure 402.01 402.11
congestive 402.01 402.11
hypertensive kidney disease (conditions
classifiable to 403) (see also Hypertension,
cardiorenal) 404.00 404.10
renal sclerosis (see also Hypertension,
cardiorenal) 404.00 404.10
intracranial, benign -- 348.2
intraocular -- --
kidney 403.00 403.10
with
heart involvement (conditions classifiable
to 425.8, 428, 429.0-429.3, 429.8, 429.9
due to hypertension) (see also
Hypertension cardiorenal) 404.00 404.10
hypertensive heart (disease) (conditions
classifiable to 402) (see also
Hypertension, cardiorenal) 404.00 404.10
lesser circulation -- --
necrotizing 401.0 --
ocular -- --
portal (due to chronic liver disease) -- --
postoperative 997.91
psychogenic -- --
puerperal, postpartum--see Hypertension,
complicating pregnancy, childbirth, or the
puerperium
pulmonary (artery) -- --
idiopathic -- --
primary -- --
with cor pulmonale (chronic) -- --
acute -- --
secondary -- --
renal (disease) (see also Hypertension, 403.00 403.10
kidney)
renovascular NEC 405.01 405.11
secondary NEC 405.09 405.19
due to
aldosternoism, primary 405.09 405.19
brain tumor 405.09 405.19
bulbar poliomyelitis 405.09 405.19
calculus
kidney 405.09 405.19
ureter 405.09 405.19
coarctation, aorta 405.09 405.19
Cushing's disease 405.09 405.19
glomerulosclerosis (see also Hypertension, 403.00 403.10
kidney)
periarteritis nodosa 405.09 405.19
pheochromocytoma 405.09 405.19
polycystic kidney(s) 405.09 405.19
polychtemia 405.09 405.19
porphyria 405.09 405.19
pyelonephritis 405.09 405.19
renal (artery)
aneurysm 405.01 405.11
anomaly 405.01 405.11
embolism 405.01 405.11
fibromuscular hyperplasia 405.01 405.11
occlusion 405.01 405.11
stenosis 405.01 405.11
thrombosis 405.01 405.11
transient -- --
of pregnancy -- --
Hypertension, hypertensive Unspecified
(arterial) (arteriolar) (crisis)
(degeneration) (disease) (essential)
(fluctuating) (idiopathic) (intermittent)
(labile) (low renin) (orthostatic)
(paraxysmal) (primary) (systematic)
(uncontrolled) (vascular) 401.9
with
heart involvement (conditions classifiable
to 425.8, 428, 429.0-429.3, 429.8, 429.9
due to hypertension) see also Hypertension,
heart) 402.90
with kidney involvement--see Hypertension,
cardiorenal renal involvement (only
conditions classifiable to 585, 586, 587)
(excluded conditions classifiable to 584)
(see also Hypertension, kidney) 403.90
with heart involvement--see Hypertension,
cardiorenal failure (and sclerosis) (see
also Hypertension, kidney) 403.91
sclersois without failure (see also
Hypertension, kidney) 403.90
accelerated (see also Hypertension, by type,
malignant) --
antepartum--see Hypertension complicating
pregnancy, childbirth, or the puerperium
cardiorenal (disease) 404.90
with
heart failure (congestive) 404.91
and renal failure 404.93
renal failure 404.92
and heart failure (congestive) 404.93
cardiovascular disease (arteriosclerotic) 402.90
(sclerotic)
with
heart failure (congestive) 402.91
renal involvement (conditions classifiable
to 403) (see also Hypertension,
cardiorenal) 404.90
cardiovascular renal disease (sclerosis)
(see also Hypertension cardiorenal) 404.90
cerebrovascular renal (disease NEC 437.2
complicating pregnancy, childbirth, or the
puerperium 642.9
with
albuminuria (and edema) mild 642.4
severe 642.5
edema (mild) 642.4
severe 642.5
heart disease 642.2
and renal disease 642.2
renal disease 642.2
and heart disease 642.2
chronic 642.0
with pre-eclampsia or eclampsia 642.7
fetus or newborn 760.0
essential 642.0
with pre-eclampsia or eclampsia 642.7
fetus or newborn 760.0
fetus or newborn 760.0
gestational 642.3
pre-existing 642.0
with pre-ecalmpsia or eclampsia 642.7
fetus or newborn 760.0
secondary to renal disease 642.1
with pre-ecalmpsia or eclampsia 642.7
fetus or newborn 760.0
transient 642.3
due to
aldosternoism, primary 405.99
brain tumor 405.99
bulbar poliomyelitis 405.99
calculus
kidney 405.99
ureter 405.99
coarctation, aorta 405.99
Cushing's disease 405.99
glomerulosclerosis (see also Hypertension, 403.90
kidney)
periarteritis nodosa 405.99
pheochromocytoma 405.99
polycystic kidney(s) 405.99
polycythemia 405.99
porphyria 405.99
pyelonephritis 405.99
renal (artery)
aneurysm 405.91
anomaly 405.91
embolism 405.91
fibromuscular hyperplasia 405.91
occlusion 405.91
stenosis 405.91
thrombosis 405.91
encephalopathy 437.2
gestational (transient) NEC 642.3
Goldblatt's 440.1
heart (disease) (conditions classifiable to
425.8, 428, 429.0-429.3, 429.8, 429.9 due
to hypertension) 402.90
with
heart failure 402.91
congestive 402.91
hypertensive kidney disease (conditions
classifiable to 403) (see also Hypertension,
cardiorenal) 404.90
renal sclerosis (see also Hypertension,
cardiorenal) 404.90
intracranial, benign --
intraocular 365.04
kidney 403.90
with
heart involvement (conditions classifiable
to 425.8, 428, 429.0-429.3, 429.8, 429.9
due to hypertension) (see also
Hypertension cardiorenal) 404.90
hypertensive heart (disease) (conditions
classifiable to 402) (see also
Hypertension, cardiorenal) 404.90
lesser circulation 416.0
necrotizing --
ocular 365.04
portal (due to chronic liver disease) 572.3
postoperative 997.91
psychogenic 306.1
puerperal, postpartum--see Hypertension,
complicating pregnancy, childbirth, or the
puerperium
pulmonary (artery) 416.8
idiopathic 416.0
primary 416.0
with cor pulmonale (chronic) 416.8
acute 415.0
secondary 416.8
renal (disease) (see also Hypertension, 403.90
kidney)
renovascular NEC 405.91
secondary NEC 405.99
due to
aldosternoism, primary 405.99
brain tumor 405.99
bulbar poliomyelitis 405.99
calculus
kidney 405.99
ureter 405.99
coarctation, aorta 405.99
Cushing's disease 405.99
glomerulosclerosis (see also Hypertension, 403.90
kidney)
periarteritis nodosa 405.99
pheochromocytoma 405.99
polycystic kidney(s) 405.99
polychtemia 405.99
porphyria 405.99
pyelonephritis 405.99
renal (artery)
aneurysm 405.91
anomaly 405.91
embolism 405.91
fibromuscular hyperplasia 405.91
occlusion 405.91
stenosis 105.91
thrombosis 405.91
transient 796.2
of pregnancy 642.3
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