How to document newly diagnosed hypertension

If a patient’s elevated blood pressure has developed into hypertension, your documentation should clearly describe the basis for the new diagnosis.

Although various sources define hypertension slightly differently, you can support your diagnosis by documenting elevated systolic pressure above 140 or diastolic pressure above 90 with at least two readings on separate office visits. There are slight variations of this for older individuals and for individuals with readings obtained through ambulatory blood pressure monitoring.

Example: Your patient, a 55-year-old female, has had blood pressure readings between 130 – 135/80 – 85 for several years. At her annual examination, you record her blood pressure as 144/92 and 142/90. You discuss with her the importance of following up and schedule another appointment for two weeks later. At that time, she again has several readings above 140/90, so you diagnose essential hypertension (ICD-10 code I10), noting the progression from prehypertension (R03.0) based on the current and prior readings.

Adapted from “How to Document and Code for Hypertensive Diseases in ICD-10.”