Health data standards and systems

While trying to follow the advice in VICC Query #3627 ACS 0010 Clinical documentation and general abstraction guidelines documented descriptions and ACS 0010 Clinical documentation and general abstraction guidelines, we have determined that our coders have been interpreting the advice differently.

Can you please provide advice on which code should be assigned for documentation of “(down arrow) BP” (assuming that it meets ACS 0002)?

1.) Can you please provide coding advice for the following examples?
a.) “(down arrow) BP - withhold antihypertensive medications”. Antihypertensive medications were withheld on the medication chart.
b.) “(down arrow) BP 80/65 – withhold antihypertensive medications”. Antihypertensive medications were withheld on the medication chart.
c.) “BP 80/65 – withhold antihypertensive medications”. Antihypertensive medications were withheld on the medication chart.

VICC Query #3627 states that the blood pressure (BP) reading is a test result and that documentation of (down arrow) BP can be coded if it meets the criteria of:
• test results (pathology report) verify that a result is abnormal AND
• there is appropriate ICD-10-AM indexing AND
• it meets the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses'

2.) Can you clarify whether coders are able to interpret the BP reading ‘test result’ as being ‘abnormal’?

Code suggestions include:
I95.9 hypotension
R03.1 non-specific low blood pressure reading

VICC advises to assign I95.9 Hypotension, unspecified for documentation of “(down arrow) BP” that meets criteria for coding, as per ACS 0002 Additional diagnoses, provided documentation verifies the BP reading is outside the normal BP range. Follow Index entry Low/blood pressure.

Therefore, for the three examples in the query VICC advises the correct code to assign is I95.9 Hypotension, unspecified providing documentation verifies the BP reading is outside the normal range and meets ACS 0002 Additional diagnoses.

When the BP result has been documented as ‘down arrow BP’ or ‘up arrow BP’, 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, provided the form indicates where the BP falls outside the normal range. This is in accordance with VICC query #3811 Abnormal blood pressure readings.

VICC advises that coders are unable to interpret the BP reading alone and need to verify that the reading is in the abnormal range within the documentation provided. VICC advises clarification should be sought from the clinician if documentation is unclear or test results are unable to be verified. This is in accordance with ACS 0010 Clinical documentation and general abstraction guidelines section titled Test results and medication charts which states ‘Where shorthand has been used to document/describe a condition, each instance must be assessed on its merits before seeking clarification from a clinician. If the documentation does not sufficiently describe a disease/condition, clinical coders should clarify the significance of the documented shorthand (test result, values, abbreviations and symbols) with the clinician to inform accurate code assignment.’

VICC notes ACS 0010 Clinical documentation and general abstraction guidelines has been updated for Twelfth Edition, however the advice still applies.