Dissecting Aneurysm and Emergent Hypertensive Treatment: Which is Principal Diagnosis?

You are reviewing a chart in which a patient is treated for hypertensive emergency and aortic dissection. The patient presented with chest pain and was rushed to CT, and a Nicardipine drip was started with clearly stated goal of SBP < 120. The thoracic surgery team is consulted. You, of course, assign a principal diagnosis of aortic dissection.

Then the coder rejects it. “The treatment was aimed at the hypertension,” she states.

Now is the perfect time to point out the ISH Practice Guidelines as a reference to differentiate the treatment guidelines for hypertensive crisis with and without aortic dissection.

Specifically: with a dissection, you are trying to get the heart rate below 60 and the systolic blood pressure below 120.

One of the tables (table 12) within the guideline set defines this, and can help with educating the coder.

The recommended treatment is with Esmolol and Nitroprusside or nitroglycerine or Nicardipine. You need to educate the coder that you are treating – and trying to limit – the dissection, by manipulation of both BP and pulse.

Remember also: this argument may NOT work for acute BP treatment for stroke, AMI and eclampsia. Chapter-specific guidelines apply