Q&A: Coding headaches for patients with hypertension

Q: If a physician orders a consultation for a patient who is experiencing a headache due to hypertension, which ICD-10-CM codes would be assigned? Would hypertension be coded since headache is a common sign and symptom of hypertension, or would both the headache and hypertension be coded? 

A: This will depend on the specifics in the physician’s documentation. If the physician treats the headache directly, then you would want to report, along with the hypertension code, the specific type of headache, such as:

• R51, daily chronic headache
• G44.52, new daily persistent headache

If the physician treats only the hypertension, such as adjusting current hypertension drug dosage, expecting that the headache will go away once the hypertension is brought back under control, then you would not need to report it separately.

Editor’s note: Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, of Safian Communications Services in Orlando, Florida, answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee. Email her at ssafian@embarqmail.com.