Coding, Classification & Reimbursement

1.  I13._, HTN/CKD/CHF

Posted 10 days ago
​I apologize for the length of this ahead of time!  I'll try to summarize as much as possible.   :)

We are being asked to review the coding of any patient with a "triad" diagnosis.  Our CHF staff are being "dinged" by Medicare for not seeing patients that have CHF coded.  They are in turn coming back to Coding and saying that we are coding CHF on patients that don't have CHF or they don't think that CHF/Triad should be the PDx..

A few examples:
1. Patient has ESRD, HTN, and chronic systolic CHF (all being treated).  The patient is admitted for treatment of the ESRD.  They feel we should assign N18.6 as PDx rather than the I13 code.

2. Patient has acute on chronic CHF, CKD and HTN and develops sepsis the day after admission.  They feel we should list the sepsis as PDx "because the patient was so sick".

Is anyone else having issues explaining certain coding scenarios to their CHF Committees?  I have given them the coding guidelines and Coding Clinics, and both CDI and Compliance have both been involved in the discussions and for most situations they have agreed with our Coding, but we are continually having to explain ourselves.  I'm just wondering if anyone else has this issue and how you've dealt with it?

Thank you!

Christine Leiphart
Inpatient Coding Supervisor

2.  RE: I13._, HTN/CKD/CHF

Posted 10 days ago

Christine- I am a CDI consultant at a hospital with this identical issue.  The issue is multifocal:


  1. The CHF staff are looking at DRGs – which are too big a bucket for what they need to do.  They need to be looking at the cases with individual codes so that they can eliminate as appropriate.  Work with your IT or BI staff to get your CHF staff a report which will give all the individual diagnosis codes as well as the DRG.
  2. I provided education to the CHF staff and the hospitalists and  cardiologists on the CHF/Hypertension/Renal diagnoses.  It is not intuitive to clinicians that they have to say that the CHF is NOT due to a diagnosis – but that is what they have to do.  I put together a logic flow chart that was very helpful to the clinicians.
  3. We also educated the CHF staff – and sat them down at the encoder and had them work through a couple of records.  Not to teach them how to code, but to teach them about the constraints of coding.
  4. We added an early CDI resource and have the CHF staff reviewing inpatients as soon at they are admitted – and are considering adding a CDI resource in the ED to catch these patients as early as possible.


If you pm me I would be happy to talk to you.



3.  RE: I13._, HTN/CKD/CHF

Posted 23 hours ago
Regarding N18.6 as PDx, N18.- has following note:

Code first any associated: diabetic chronic kidney disease (E08.22, E09.22, E10.22, E11.22, E13.22) hypertensive chronic kidney disease (I12.-, I13.-)

I wonder if the payers even know about "code first" rules that would make certain diagnoses invalid as Principal because they violate Code First?

Since the Guidelines state on page 1 "Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings."

In my opinion, coding that deviates from guidelines is out of compliance with the HIPAA requirement that we use ICD-10 codes correctly!

Bill Roush, RHIT, AHIMA-Approved ICD-10-CM Trainer

4.  RE: I13._, HTN/CKD/CHF

Posted 10 hours ago
​I don't think the payers know about the code first guidelines. I code for Home Health and SNF and in Home Health we list the primary code based on what the focus of care is... we do follow the coding guidelines so when the patient has hypertension, CHF and CKD we list the hypertension first even though the focus of care is on the CHF.

I am pretty sure the payers are not aware of most of the code first guidelines cuz forever we didn't realize that there was a code first note for CAD. So if the patient has CAD, hypertension, CHF and CKD the CAD is also coded prior to the hypertension. If they had an MI that also is listed prior to hypertension. So if you have a patient with primary care focused on CHF and they had MI in last 4 weeks, plus CAD, hypertension, CHF and CKD you would code it as follows:


Even though the CHF might be focus it is not listed's now your 4th code. In Home Health it's a big deal cuz only the first 6 dx codes count.

Brenda Mohs
Essentia Health-Sandstone

5.  RE: I13._, HTN/CKD/CHF

Posted 3 hours ago
I agree with you, Christine!

This is clearly a case of Guidelines in Chapter 9 (I.C.9.a.3) - Hypertensive Heart & Chronic Kidney, I13.--. The guidelines state that Chronic Kidney Disease should be assigned as a SECONDARY CODE. In Tabular, we have section instructions telling us to assign a ADDITIONAL codes for both Heart Failure (I50.--) and Chronic Kidney Disease (N18.--)

The chapter guideline notes state the classification presumes a causal relationship and links the conditions. It explains that these conditions should be coded as related EVEN IN THE ABSENCE of provider documentation explicity linking them. This is always a little uncomfortable in my book -- maybe a quick query to get this documentation is in order?? -- but at least we coders have a legal defense, as it were, for coding these conditions without linkage documentation.

As we know, the PDx is the Dx that, after study, is responsible for the admission. So in your Sepsis example -- if the sepsis clearly developed sometime after admission, it could not be the PDx. And furthermore, that would get a big, fat "N" for POA. We coders know that the "seriousness" of a condition is NOT always the principle condition.

Would it be possible to explain to whomever you're dealing with at Medicare that you will not be compliance if you code things differently? This is a textbook example (based on the info you provided) of following guidelines. I'm surprised you're getting push-back from Medicare and not a third-party payor.

I'd love to hear more from the rest of the community.

Thank you!
Cynthia Kibbe