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CKD plus hypertension diabetes, and dialysis

By Therese M. Jorwic, MPH, RHIA, CCS, CCS-P

March is National Kidney Month, so here’s a look at the coding for chronic kidney disease, or CKD, which affects 26 million adults in the U.S.

CKD often goes undiagnosed because its symptoms – energy loss, swollen feet and eyes, frequent urination, and so on – may not appear until it reaches the later stages.

The disease gradually reduces kidney function and can progress to end-stage renal disease or ESRD requiring dialysis and even kidney transplant. Along the way, it can cause complications such as anemia, osteoporosis, and nerve damage.

CKD’s most frequent causes are diabetes and hypertension, and conversely, it can cause hypertension. Less commonly, it’s caused by glomerulonephritis or inflammation of the filtering units, by inherited diseases such as polycystic kidney disease, and by malformations, autoimmune diseases, obstructions, and repeated urinary infections.

coding its five stages

There are five stages of CKD, each based on the glomerular filtration rate, or GFR, which measures kidney function. They are

Stage I (GFR ≥ 90): normal function but evidence of disease

Stage II (GFR 60-89): mild reduction of function

Stage III (GFR 30-59): moderate reduction

Stage IV (GFR 15-29): severe reduction

Stage V (GFR < 15): kidney failure with dialysis often required

The ICD-9-CM codes are found in the 585 category, and they follow that pattern with the fourth digits. Code 585.1 is Stage I, 585.2 is Stage II, and so on to 585.5 for Stage V.

However, a note under the Stage V code says that if the condition calls for regular dialysis, use the next code, 585.6, for ESRD with dialysis required.

coding CKD with hypertension

Hypertension often accompanies CKD.

It is a leading cause of the disease, because it damages blood vessels throughout the body and reduces the blood supply to the kidneys as well as to the other organs. It also damages the filtering units within the kidneys.

On the other hand, CKD can cause the hypertension, because the diseased kidneys have difficulty regulating the blood pressure.

• The hypertension causes the CKD.

If both conditions exist when the CKD is first diagnosed, the assumption is that the hypertension caused the disease.

Then the condition gets coded either in category 403 (hypertensive CKD) or, if there is also heart disease, in category 404 (hypertensive heart and CKD).

Both categories have fourth digits to show whether the hypertension is malignant, benign, or unspecified.

Both also carry fifth digits to show the general stage of the CKD – whether it falls within Stages I – IV or is Stage V. A note there says to use a second code in the 585 category to show the exact stage.

So suppose there’s hypertensive CKD, Stage V, with hypertension and the patient is not on dialysis. The first code is 403.01, and the second is 585.5.

Or, if the patient also has heart disease but not heart failure, the first code would be 404.02 with the fifth digit showing the heart failure. And the second code would again be 585.5.

• The CKD causes the hypertension.

On the other hand, if the hypertension has developed as a result of the CKD, it’s considered secondaryto the CKD, and the code goes to the 405 category forsecondary hypertension.

Once again, there are fourth digits to show whether the hypertension is malignant, benign, or unspecified. A fifth digit of 1 then shows that the renal disease is the cause of the secondary hypertension.

CKD caused by diabetes

Another leading cause of CKD is diabetes. And when that’s the case, the code is in the 250 category, which covers diabetes mellitus.

Use a fourth digit of 4 to show that it’s diabetes with renal manifestations, and then use a fifth digit to show the type of diabetes and whether it is controlled or not.

And then use a 585 code for the CKD.

dialysis: the V codes

What if the patient is on dialysis?

There are two V codes, one to show dialysis status (V45.11) and the other to show that the patient has come in for dialysis treatment (V56.0).

So suppose a patient who is on dialysis comes in for an MRI to diagnose a heart problem. Use V45.11 to show the dialysis status. (There is also the relatively new code V45.12 to show noncompliance with dialysis.)

However if the patient comes in for dialysis treatment, the code is V56.0 for encounter for dialysis.

dialysis: the CPT codes

Finally, there are CPT codes for the dialysis, and they are found in the medicine section.

Codes 90935 and 90937 are for all the E/M services related to the renal disease that are given on the day of the dialysis.

They are used for inpatients, both ESRD and non-ESRD, and also for non-ESRD outpatients. The latter would apply when a trauma or some other illness has caused the kidneys to fail.

Code 90935 shows the physician evaluates the patient only one time during the dialysis whereas code 90937 shows repeated evaluations.

For outpatient ESRD services, the codes are 90951- 90962. Those are used just once per month, and they are determined by the patient’s age and the number of face-to-face visits.

They include a lot of services – setting the dialysis cycle, the E/M services provided, phone calls, and patient management, and again, they are used just once no matter how many times the patient receives dialysis during the month.

For home ESRD services, the codes are 90963-90970.

Those too are determined by the patient’s age, but they do not specify the number of visits. Instead, codes 90963-90966 apply to a full month of services, and codes 90967-90970 are used per day when the services are provided for less than the full month.

The codebook gives the example of outpatient ESRD services begun July 1. Then on July 11 the patient is hospitalized, and on July 27 he is discharged. There are two face-to-face visits before admission and one after discharge.

The codes are 90961 for the three face-to-face out-patient visits and 90935/90937 or 90945/90947 for the dialysis.

(The National Kidney Foundation has a 10-question online quiz on kidneys. To access it click here.)

Therese M. Jorwic, MPH, RHIA, CCS, CCS-P, is assistant professor of health information management at the University of Illinois at Chicago and senior consultant for MC Strategies in Atlanta.









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