Coding, Classification & Reimbursement

Ckd cause by Hypertension and DM

  • 1.  Ckd cause by Hypertension and DM

    Posted 11 days ago
    Regards,

    If the physician documents CKD caused by the hypertension and additional patient has DM, how will the coding rules for this particular scenario be followed, taking into account the with rule in the book index?

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    Evelia Nater
    Coder
    Medical Card Systems Inc
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  • 2.  RE: Ckd cause by Hypertension and DM

    Posted 11 days ago
    ​Hello!

    It depends on how you interpret the Guideline which is worded a little ambiguously.  This has been discussed in the past in this forum. "These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated..."  Some interpret this as meaning all possible associated conditions must be explicitly documented as unrelated.  Others, like myself, believe it means that if a specific link between the conditions is made, then other assumed links are ruled-out.

    Based on the information you provided, I would code the I12.9 and the appropriate CKD code.  I would not assign the combination code for DM with CKD.  I have argued about this in the past in this forum.  I believe an explicit connection between two conditions implies any other possible connections do not exist.  Others believe all assumed relations must be explicitly documented as unrelated.

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    Lawrence Barr
    President
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  • 3.  RE: Ckd cause by Hypertension and DM

    Posted 10 days ago
    It is very clear from the documentation you provided that the CKD is only related to the HPN and nothing else.... so 112.9 with the CKD code and DM should be coded.... Diabetic CKD is not appropriate as the guideline states " unless the condition is due to a different etiology"... in this case the CKD is only related to HPN...
    This is also along the lines of L. Barr's logic...
    Unless the coding committee change the verbiage of this coding guideline, this was the intent when it was written...

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    Josefino Lim
    CODER II
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  • 4.  RE: Ckd cause by Hypertension and DM

    Posted 10 days ago

    ​Hello!

    The provider clearly stated the CKD was due to the hypertension, not the diabetes.

    For another example, look at the main term "anemia" and the subterms "with", "due to" and "in".  According to The Guideline these terms are all equivalent and at the same level of indentation.  What if a patient is admitted with a GI Bleed and also has so form of cancer currently treated with chemotherapy, chronic kidney disease and some sort of vitamin or mineral deficiency.  The provider specifically documents the patient has anemia due to acute blood loss but does not "clearly state" the anemia is not due to the other associated conditions.  How many anemia codes are you going to assign?  One for the acute blood loss anemia or a total of five for the other conditions the physician did not explicitly state were not related?  Are you going to query the physician every time this situation occurs?

    I believe when a physician specifically documents what the underlying cause of a condition is, the other possible "with" conditions are implied to be not associated.  Also, keep in mind that it is not just the Index, but also the Tabular List that the "with" Guideline applies.  It is right there in the guideline.  What if the same patient comes in with a GI bleed and undergoes both a colonoscopy and an EGD.  During the colonoscopy the patient is found to have diverticulosis and during the EGD is found to have gastritis, a gastric ulcer, and duodenal AVMs.  The physician specifically documents the GI Bleed is due to the gastric ulcer but does not "clearly state" the GI Bleed is not related to the other documented conditions.  How many GI diagnoses "with hemorrhage" are you going to assign, one or four?  I believe the physician has clearly documented the cause of the GI Bleed and the other conditions should be documented as "without".

    If you believe that all conditions that involve the "with", "due to", or "in"  association must have all possible associated conditions clearly documented as being unrelated even in circumstances where the provider clearly documents the condition is associated with only one condition then you better consistently assign all possible associations or query the provide to be sure only one diagnosis was associated with the condition.



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    Lawrence Barr
    President
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  • 5.  RE: Ckd cause by Hypertension and DM

    Posted 11 days ago
    ​With the clarifications in the FY 2019 Coding Guidelines - I would say that since Chronic Kidney Disease is in the index as a subterm under DM, with we have to code them together unless the provider has document that they ARE NOT related.

    "with" These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated...

    We code both the Hypertensive CKD and the Diabetic CKD.

    Am interested in what others are doing.

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    Kathy Completa
    Coding and Documentation Educator
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  • 6.  RE: Ckd cause by Hypertension and DM

    Posted 11 days ago
    Edited by Evelia Nater 11 days ago
    Hello!!

    Very grateful for your answer.

     I understand that this topic is a bit confusing. Rather because the guide indicates that there is in itself a connection between the hypertension and the CKD and in case they would be related even when the provider does not indicate it. So I understood that it was blind to me, the fact that the condition was independently established as related. For example, the patient suffers from CKD and has HCVD and has DM, it would be codified I13.10 and E11.22 + N18.9.

    As indicated in the example of the book: "Diabetic kidney is coded to E08-E13 with .21 for diabetic nephropathy, .22 for chronic kidney disease, and .29 for other kidney complications. Kidney disease sometimes results from both hypertension and diabetes In this situation, the combination code from category I12 or category I13 and a code from subcategory E08-E13 with .2- are assigned. A code from category N18 is assigned to specify the stage of chronic kidney disease.

         Examples of appropriate codes for kidney disease due to diabetes include the following:



     E11.21 Diabetic nephrosis
     I12.9 + E10.22 + N18.4 Chronic kidney disease stage 4 due to hypertension and type 1 diabetes mellitus
     E10.22 Chronic kidney disease, unspecified, due to type 1 diabetes.

    It is confusing, they excuse the inquiry into the matter and the recurring doubts about it.
    Thank you very much for answering.

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    Evelia Nater
    Coder
    Medical Card Systems Inc
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