August 10, 2017 | | Comments 0
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Q&A: Coding chronic kidney disease, hypertension, and diabetes mellitus

LauriePrescott_May 2017

Laurie L. Prescott, RN, MSN, CCDS, CDIP, answered this question

Q: Let’s say a provider documented chronic kidney disease (CKD), 2/2 hypertension (HTN), and diabetes mellitus (DM), and the stage of CKD was not specified, but lab results show patient was in stage 2. Could I assign codes for CKD, stage unspecified, Hypertensive CKD w/ stage 1-4, and Type II DM. Do I need to assign a separate code for HTN?

A: Let’s break down the documentation.

CKD secondary to HTN and DM: With this documentation, we have two combination codes to assign—hypertensive CKD and diabetic CKD. We would also assign a code to reflect the stage of the CKD.

So, let’s say the patient has diabetes type 2, CKD, and HTN. The codes you would assign are:

  • Type 2 diabetes with CKD—E11.2
  • Hypertensive CKD—I12.9 (with stage 1-4 and unspecified CKD)

If the provider did not specify the stage of CKD, we would assign the code for CKD unspecified—N18.9. But as a CDI specialist, you’re likely going to query for the stage based on the labs.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.

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Filed Under: ACDISBoot CampCDI ProfessionClinical Documentation ImprovementClinical indicatorsCodingPhysician queries

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Linnea Archibald About the Author: Linnea Archibald is the CDI editor for the Association of Clinical Documentation Improvement Specialists (ACDIS). In this role, she helps out with the website, blog, social media, newsletter, and the CDI Journal. If you have any questions, feel free to email her.

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