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Accelerated hypertension

From the October ACP Hospitalist, copyright © 2010 by the American College of Physicians

By Richard D. Pinson, FACP

Sidebar: Ask Dr. Pinson

Why is an archaic term like “accelerated” necessary for the correct documentation and coding of severe hypertension? Unfortunately, coding terminology hasn't caught up with the currently accepted clinical diagnostic terms for severe, uncontrolled hypertension.

Terms such as “hypertensive emergency,” “hypertensive crisis,” “hypertensive urgency,” “severe hypertension,” “malignant hypertension” and “accelerated hypertension” are all used in the literature and often overlap. Yet “accelerated” and “malignant” hypertension are the only terms that will code to a serious, severe or problematic hypertensive condition. The terms “hypertensive urgency,” “hypertensive emergency” or “hypertensive crisis” alone will be classified to a non-specific or benign hypertension code having virtually no clinical significance.

A patient with hypertension that is defined as “accelerated” or “malignant” should require urgent treatment (either IV or STAT oral dosing); have the same risks and clinical implications as urgent or emergent hypertension; and meet one of the following criteria:

• systolic blood pressure (BP) >180 mm Hg, or
• diastolic BP >110 mm Hg, or
• symptoms attributable to the hypertension (e.g., headache, dyspnea or chest pain), or
• end-organ involvement/damage (e.g., neurologic, renal or cardiac damage).

How do these criteria for accelerated hypertension compare with more current terminology?

• “Hypertensive urgency” is defined as having blood pressure >180/110 mm Hg, with or without symptoms like severe headache, shortness of breath and anxiety, and no end-organ involvement.
• “Hypertensive emergency” is usually symptomatic with blood pressure >180/120 mm Hg, and end-organ involvement. Possible symptoms include chest pain and neurologic deficits.
• “Hypertensive crisis” is used to describe the spectrum of severe, uncontrolled hypertension that includes both urgent and emergent hypertension, as described above.

Examples of documentation that combines current clinical terms with what's needed for correct coding are “accelerated hypertension with hypertensive emergency” and “hypertensive urgency due to accelerated hypertension.”

Richard Pinson, FACP, is a certified coding specialist and co-founder of HCQ Consulting in Houston. This content is adapted with permission from HCQ Consulting.

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Ask Dr. Pinson

Q: An acute ischemic stroke patient is treated with thrombolytics by one hospital, then transferred to another hospital for a higher level of care (like an intra-arterial procedure or endovascular treatment). Which hospital gets to bill for MS-DRGs 61, 62 and 63 (acute ischemic stroke with use of thrombolytic agent with MCC, with CC, and without MCC/CC, respectively).

If both hospitals end up billing for the same MS-DRGs, who gets the reimbursement? Or is it prorated accordingly?

Thuy Nguyen, PharmD
Houston, TX

A: If the transferring (outside) hospital admits the patient to inpatient status, it would bill the claim as acute ischemic stroke with use of thrombolytic agent (MS-DRGs 61-63). The specific DRG depends on whether or not the patient also had any significant comorbid conditions designated by CMS as CCs or MCCs.

DRGs 61-63 are included in a group of DRGs identified by CMS as subject to post-acute care transfer (PACT) rules. For these DRGs, if the patient's length of stay (LOS) at the transferring hospital was shorter than the nationwide average (geometric mean LOS) at the time of transfer, the hospital's reimbursement is reduced based on a formula that compares the actual LOS with the geometric mean LOS. These rules also apply to transfers from acute care to skilled nursing facilities, inpatient rehab or home health.

The receiving hospital will bill its claim based on the DRG assigned according to the care provided there. The receiving hospital will be reimbursed the full payment amount for that DRG (even if it is the same), unless the DRG is also subject to PACT rules at discharge. In this particular case, the receiving hospital would not re-administer thrombolytics, so DRG 61-63 would not be assigned.

Got a documentation or coding conundrum? Each month, Dr. Pinson will respond to selected questions from readers. Please e-mail us your questions.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated