Health data standards and systems

We are seeking clarification on the advice in VICC 3627 ACS 0010 Clinical documentation and general abstraction guidelines documented descriptions and how to code documentation of (down arrow) BP or (arrow up) BP. We note that test results are required to verify that a BP reading is abnormal, i.e. high or low, but are unsure if documentation on an observation chart is sufficient to verify BP readings are abnormal.

Our observation chart has colour coded sections with instructions on the actions required to be taken if the blood pressure is within a particular coloured area / blood pressure ranges unless a modification has been made on the chart. For example blood pressure in the range of 180s - 190s is colour coded yellow ‘Clinical Review’, the actions required include alerting the nurse in charge / notifying VMO and requesting a review.

In the Modifications section of the observation chart, blood pressure readings that are abnormal but are tolerated for the patient’s clinical condition can be documented. The observation chart does not define blood pressure readings with the terms ‘low’ or ‘high’.

1. Can VICC please provide advice on the code to assign in the following scenario?
A doctor documented in the progress notes: ‘BP 80/60, Diagnosis: (down arrow) BP, Plan: Withhold antihypertensive medication (perindopril)’. Perindopril was withheld on the medication chart.
On the Observation chart there is documentation the patient’s BP was 80/60 on the same date as the progress note entry from the doctor. This BP reading is in the purple ‘Code Blue/MET Call’ area on the observation chart.
There is no modification documented on the observation chart which indicates a BP reading of 80/60 is abnormal but is to be tolerated for the patient’s clinical condition.

• Does the blood pressure reading 80/60 being in the Code Blue/Met Call criteria area on the observation chart verify that the blood pressure reading 80/60 is abnormal, and therefore the diagnosis of ‘(down arrow) BP’ should be interpreted to mean ‘low’ and the Index entry: Low / blood pressure (see also Hypotension) should be followed to assign the default code I95.9 Hypotension, unspecified?

2. Can VICC please provide other examples of test results which would be sufficient to verify that a blood pressure reading is ‘low’ or ‘high’?

Further to the advice in VICC #3627 ACS 0010 Clinical documentation and general abstraction guidelines documented descriptions, VICC considers it is appropriate to use observation charts and other forms of documentation where blood pressure results are recorded to verify if a blood pressure reading is low or high when the BP result has been documented as ‘down arrow BP’ or ‘up arrow BP’. This is provided the form indicates where the BP falls outside the normal range and there are no modifications (observations that are to be tolerated for the patient’s clinical condition) to indicate that the test may be normal for that patient. VICC is aware that an EMR may not display ranges within the observation chart itself but there is ability for a clinician to identify an abnormal reading.

Therefore, for the scenario cited, VICC advises to assign I95.9 Hypotension, unspecified because:
- shorthand (down arrow) BP has been used to document/describe a condition
- the test results (documented on the observation chart) verify that the result is abnormal
- there is appropriate ICD-10-AM indexing (Low/blood pressure)
- low blood pressure meets the dot point of ACS 0002 Additional diagnosis, Commencement, alteration or adjustment of therapeutic treatment because antihypertensive medication (Perindopril) was withheld in response to hypotension.
See also VICC #3832 (down arrow) Blood pressure (BP)