The patient’s blood pressure must be measured and recorded in the Physical Exam window. To access the Physical Exam area, with the patient account open, click on either the Objective icon or the Exams button.
From the Objective window, click on the button for Physical
Or from the Exams button, select Physical
After measuring the Blood Pressure, enter it in the appropriate location. If the blood pressure was measured in both arms, enter each finding. Be sure to click the save icon after making the entry.
As soon as the SOAP note is generated, this information will generate in the documentation. If it does not, verify that the Note Options are set correctly on the documents window.
However, just checking the blood pressure is NOT enough for Meaningful Use. The appropriate diagnosis code must be used. The Diagnosis Window is accessed in the Assessment section. Click the Assessment icon. When the Assessment Window opens, click on the Diagnosis Sets tab.
Now verify that the correct ICD9 diagnosis code is in the patient’s Diagnosis window.
If the blood pressure was normal, use code V81.1 Screening for Hypertension.
If the blood pressure is elevated, use one of the codes in the 401 series, either as a stand-alone item or together with the V81.1.
•401.0 Malignant Essential Hypertension
•401.1 Benign Essential Hypertension
•401.9 Unspecified Essential Hypertension
o This applies to hypertension when there is NO pre-existing kidney disease or any other known organic cause.
The combination of recording the blood pressure and using the ICD 9 code is what will generate the numbers and percentages for the hypertension blood pressure screening for Meaningful Use.
In your billing, make sure the appropriate PQRS (G codes and/or CPT II) codes are used. Usually only one, and sometimes 2, of these codes are used on one visit. These codes include:
•G8675 Hypertension systolic greater than 140 mmHg
•G8676 Hypertension diastolic greater than 90 mmHg
•G8677 No hypertension systolic less than 130 mmHg
•G8678 Potential hypertension systolic between 130 to 139 mmHg
•G8679 No hypertension diastolic less than 80 mmHg
•G8680 Potential hypertension diastolic between 80 to 89 mmHg
•4050F Hypertension plan of care documented