ICD-10 Code for High Cholesterol: Coding Guidelines and Common Errors

From a coding perspective, hypercholesterolemia (high cholesterol) must be approached with accuracy because it pertains to one of the several metabolic anomalies and it relates to the formation of several cardiovascular diseases (e.g., coronary artery disease, stroke, and peripheral vascular disease) that affect the blood circulation), the coding and billing process should capture the relevant documentation and the appropriate ICD-10 code to defend the medical necessity of the claim to facilitate a clean claim and to be compliant with regulations; therefore, because the disorders of lipids present different forms and divergent levels of severity, coding a disorder of lipids is as complex as differentiating the ICD-10 code.

ICD-10 Coding and Lipid Disorder

Using the classification of diseases- ICD 10, the code assigned to describe a disorder of lipid metabolism is E78 (which refers to disorders of lipoprotein metabolism and other lipidemias). E78 is subcategorized to hypercholesterolemia, hypertriglyceridemia, mixed hyperlipidemia and unspecified hyperlipidemia each having several other descriptive codes. To be as accurate as possible, a complete review of documentation from the provider must be conducted, as a result of which the coder is able to establish which lipid fraction is excessive and if that condition is primary, secondary, or unspecified. More specific coding yields a higher, quality data outcome, as well as less denial or audit risk.

The Codes Used for Hyperlipidemia: Primary and Secondary

The default ICD-10 code, for high cholesterol, as described in the documentation, is E78.00 – Pure hypercholesterolemia, unspecified. This code is reported when the provider documents elevated cholesterol levels without further specification regarding the type or underlying cause. Pure hypercholesterolemia is defined as the elevation of cholesterol which is the low density lipoprotein (LDL) without significant elevation of any of the triglycerides. In cases where documentation states, “high cholesterol” or “hypercholesterolemia” without any additional detail or description, the E78.00 code is appropriately used.

Other ICD-10 Codes Documented for Hyperlipidemia

In some cases, providers may document more specific lipid abnormalities. For example, E78.01 – Familial hypercholesterolemia is used when the condition is genetic and documented as such. E78.2 – Mixed hyperlipidemia applies when both cholesterol and triglyceride levels are elevated. E78.5 – Hyperlipidemia, unspecified, be used when the provider does not differentiate between cholesterol and other lipid abnormalities. Understanding these distinctions allows coders to avoid defaulting to general codes when more precise options are supported.

Developing Clinical Documentation Skills

Providing correct clinical documentation skills helps with correct coding. Providers are required to mention and explain the different types of lipid abnormalities, if the disorder was inherited or acquired, and other abnormal conditions, such as, diabetes, obesity, or drugs. Reports should also document the clinical significance of the lipid abnormality, such as the necessity of drugs, alterations of lifestyle, or continuous observation. Documentation of such significance may cause the coders to direct questions to the providers in order to receive additional information for accurate coding.

Clinical Hypothesis Regarding Hypercholesterolemia

Documentation of clinical assessment, treatment, and monitoring falls under the same ICD-10 coding guidelines for the clinical assessment, treatment, and monitoring of abnormal cholesterol. Hypercholesterolemia should be documented and coded as a diagnosis, and as a contributing factor in the management of the patient. If a clinician has not assessed an abnormal lipid profile or given a clinical diagnosis, it should not be coded. In addition, ICD-10 coding guidelines concerning the combination of codes, unspecified codes, and the order of codes should be applied when hypercholesterolemia is coded with any other coexisting disease, such as hypertension or diabetes

Considerations When Coding For Chronic High Cholesterol

Chronic high cholesterol is often listed as a secondary diagnosis/filter diagnosis when a patient is being seen for an acute issue. However, if the appointment is for the evaluation and management of hypercholesterolemia, the E78 code must be sequenced as the primary diagnosis. Coders must consider the reason for the visit, the assessment, and the action plan for correct coding sequencing, and should be consistent with the coding guidelines and any payers’ guidelines.

Justifying High Cholesterol as a Reason for Medical Necessity

Payers often question the medical necessity of services tied to lipid testing, medication outputs, and follow-up visits. Justifying these services with the correct ICD-10 codes is important. For example, E78.00 linked to a lipid panel can be deemed medically necessary in terms of frequent testing. Documenting and coding high cholesterol provides justification for prescribing statins or other lipid-lowering agents. Coding that is insufficient, incorrect, or not done can lead to claim denials or payment reimbursements being delayed.

Common Coding Errors

The incorrect coding of E78.5 (Hyperlipidemia, unspecified) is one of the most common coding errors, despite the report of a provider documenting hypercholesterolemia, which should be E78.00, leading to a loss of coding specificity, which in turn increases the likelihood of a payer query. A similar problem occurs when diagnosis codes are assigned based on abnormal lipid values from a laboratory report that were not evaluated by a provider or of which there is no provider diagnosis, thus no record is available that justifies the coding. In addition, coders tend to code for familial hypercholesterolemia in the absence of documentation of a genetic component in the record. Moreover, the increased dependence on unspecified codes when there are more specific options available can lead to claim denials, lagging payments, and diminished overall quality of the clinical data.

Impacts of Upcoding and Undercoding

“High cholesterol” is documented and then familial hypercholesterolemia is reported. This is an example of upcoding where a more severe code is assigned without the requisite documentation. Undercoding occurs in the opposite scenario. Both of these practices result in empty documentation and are among the more serious practices in coding. They can leave an organization exposed to audits and a loss of revenue because these practices apply severe vague coding to a documented problem.

Documentation Improvement Strategies

With more information required in coding, the expectation is that documenting more about the type of lipid abnormality, the cause of the hyperlipidemia, and the treatment can improve coding. Technology, such as EHR templates that require specific information, can also facilitate quality coding. Educating and communicating with coders regularly can assist in these areas.

The Impact of Risk Adjustment and Quality Reporting

Coding accuracy in the case of chronic conditions such as high cholesterol is important in some risk adjustment and quality reporting programs. While hypercholesterolemia may not carry as much weight as other chronic diseases, it does reflect disease burden and aids in documenting the level of comprehensive care delivered. The coding accuracy keeps the clinical data consistent and usable for effective management of the population’s health.

Payer-Specific Considerations

Coding accuracy in the case of chronic Payers differ on coverage requirements for lipids testing and prescribing the medication. Some might need documents showing specific lipid abnormalities instead of hyperlipidemia. Let the coders and billers know the policies so they can design their claims to fit the requirements and lower the chances of a claim being denied.

Compliance and Audit Readiness

Compliance with ICD-10 and payer guidelines is the first step to being ready for an audit. Periodic internal reviews of lipid disorder coding should be done to spot and address the gaps in error. Training and sticking to the guidelines is proof of compliance in good faith.