Elevated blood pressure reading without diagnosis of hypertension

This code signifies an isolated finding of elevated blood pressure during an encounter, without a definitive diagnosis of hypertension being established by the provider. It indicates that the blood pressure reading is higher than normal, but further evaluation is needed to determine if the patient has chronic hypertension. This is often a transient finding or an initial observation.

Use this code when a patient presents with an elevated blood pressure reading, but the physician explicitly states that hypertension is not yet diagnosed or ruled out. This is appropriate for screening encounters, follow-up visits where hypertension is being monitored but not confirmed, or when the elevated reading is attributed to acute stress or "white coat syndrome." Documentation should clearly state "elevated blood pressure," "borderline hypertension," or "hypertension not yet diagnosed."

• Do not use this code if the physician has definitively diagnosed hypertension (e.g., essential hypertension, secondary hypertension).
• Consider sequencing this code as a secondary diagnosis if the primary reason for the encounter is unrelated to the blood pressure finding.
• Ensure documentation supports the lack of a definitive hypertension diagnosis; otherwise, a more specific hypertension code should be used.