Home Health ICD-9/ICD-10 Alert

Question: Our new patient has diabetic chronic kidney disease (CKD) and hypertension (HTN). I know that we can assume a relationship between the HTN and CKD but that you also would need to list the same CKD code under the DM with Renal manifestations. However, you can't list the same code (CKD) twice. How should I code for this patient?

Answer: If you have documentation that the chronic kidney disease is a manifestation of the patient's diabetes and assuming that this particular manifestation is the focus of care, you should sequence your codes as follows:

M1020a: 250.40 (Diabetes with renal manifestations; type II or unspecified type, not stated as uncontrolled);

M1022b: 403.90 (Hypertensive chronic kidney disease; unspecified; with chronic kidney disease stage I through stage IV, or unspecified); and

M1022c: 585.9 (Chronic kidney disease, unspecified).

When a patient has both chronic kidney disease and hypertension, assume the two conditions are related. You should report the hypertension with a code from the 403.x (Hypertensive chronic kidney disease) category instead of using one from the 401 (Essential hypertension) category.

You're right that you shouldn't list the CKD code twice. Listing it once, paired with the diabetes -- your focus of care -- is sufficient. If the patient has diabetic CKD and also has HTN, there are two sequencing rules that both apply. First, there is a rule similar to the etiology/manifestation rule for the diabetic CKD and second, there are instructions in the tabular list and the guidelines regarding hypertensive chronic kidney disease.

The diabetes must precede the CKD and the hypertension must precede the CKD, hence the sequencing above. Remember, the separation of the CKD from the diabetes is okay because the CKD code is not a true manifestation -- it doesn't appear in italics in the tabular list, nor does it say to code diabetes first.