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Internal Medicine Coding Alert

ICD-9 2006 Expands Your CKD Coding Options

Published on Sun Jun 26, 2005

Tip: Use a patient's disease stage to pick the right code

If your internist manages or diagnoses patients with chronic renal failure, you'll need to chuck deleted code 585 and add seven new kidney-disease ICD-9 codes to your charge sheets by Oct. 1, when the codes take effect.

And you should get ready for the revised definition and fifth-digit classification of nine hypertensive kidney-disease codes.

Report CKD in Stages

When your internist treats a patient who has had chronic kidney disease (CKD) for longer than three months, you'll need to use one of the codes from the 585.1-585.5 series, which describe the disease in five stages. CMS also introduced a new end- stage renal disease code and an unspecified CKD code.

"The expanded CKD classification allows the coder and the physician to paint a clearer picture of the patient's condition and, in turn, may justify the appropriate course of treatment," says Tara Conklin, CPC, an independent coding consultant in Wesley Chapel, Fla.

Quick tip: The 585 category's fourth digits simply specify in chronological order the five CKD stages from least (stage I) to greatest severity (stage V). So, if the medical notes say the patient has stage III CKD, you would list 585.3.

The new codes are:
 

  •  585.1 - Chronic kidney disease, stage I. Use this code for patients who have kidney damage with normal or increased glomerular filtration rate (GFR), greater than or equal to 90 ml/min/1.73m.
     
  •  585.2 - ... stage II (mild). This code represents kidney damage with mild decrease in GFR, 60-89 ml/min/1.73m.
     
  •  585.3 - ... stage III (moderate). List this code when the patient has a moderate decrease in GFR, 30-59 ml/min/1.73m.
     
  •  585.4 - ... stage IV (severe). In this case, there has been a severe decrease in GFR, 15-29 ml/min/1.73m.
     
  •  585.5 - ... stage V. You'll need this code for two conditions: kidney damage with GFR of less than 15 ml/min/1.73m, or kidney failure with GFR less than 15 ml/min/1.73m (the patient isn't on dialysis).
     
  •  585.6 - End-stage renal disease. Report this code if the patient has stage V kidney disease and is on dialysis.
     
  •  585.9 - Chronic kidney disease, unspecified. Use this code for chronic renal insufficiency and chronic renal failure NOS (not otherwise specified).

    Code a Typical CKD Visit

    Physicians typically order or perform tests to get the patient's GFR, which helps them determine the CKD's stage, says Annette Grady, CPC, CPC-H, senior healthcare consultant at Eide Bailly LLP in Bismarck, N.D. To ensure reimbursement for these tests, you'll need to report the appropriate E/M code (99201-99215) or lab code (if your office has a certified lab), in addition to 585.1-585.5.

    For example, a patient presents with possible CKD. The internist orders the nurse to document the patient's medical history, and the internist performs the exam. Then, the physician orders blood creatinine (82565) and urine protein tests (84156, Protein, total, except by refractometry; urine) to check the GFR. Based on the history, exam and test results, your internist diagnoses stage I CKD. For the tests, history, decision-making and exam, you report 99213 (Office or other outpatient visit ... established patient ...) along with 585.1 as the primary diagnosis.

    Remember that you can list symptom codes, such as diabetes (250.xx), as secondary diagnoses.

    Documentation tip: The 585.x codes have dropped "chronic renal failure" in the descriptor. The medical documentation should specify CKD rather than imprecise terms, such as chronic renal failure and chronic renal insufficiency, Grady says.

    CMS deleted "renal failure" because many kidney patients suffer from associated diseases, such as hypertension (401.x), and have not advanced into the "organ failure" state, Conklin says.

    Welcome This 'Hypertensive' Makeover

    Next year you'll have revised descriptors and fifth digits to work with when coding hypertensive renal disease and hypertensive heart and renal disease diagnoses. These changes should make your ICD-9 coding more specific and easier.

    In the 403.xx series, CMS revised the descriptor "hypertensive renal disease" to "hypertensive kidney disease." Also, as of Oct. 1, fifth-digit "0" will represent "without mention of chronic kidney disease," while fifth- digit "1" will describe "with chronic kidney disease."

    Now the fifth digits define with and without mention of "renal failure."

    Further, CMS changed the 404.xx series code descriptor from "hypertensive heart and renal disease" to "hypertensive heart and kidney disease." You should note the two revised fifth digits, as well. The changes are as follows: 

  •  0 - without heart failure or chronic kidney disease. The current descriptor reads, "without mention of heart failure or renal failure."
     
  •  2 - with chronic kidney disease. CMS deleted the "with renal failure" definition.

    "This is another welcome expansion of current ICD-9 codes," Conklin says. "These changes allow for greater freedom in providing an accurate diagnosis for patients suffering from hypertension associated with heart and renal disease."

    Now you can use the hypertensive renal disease ICD-9 codes only for patients who have kidney failure, even though more patients have hypertension caused by chronic kidney insufficiency, she says.

    Helpful: With these revisions, you no longer have to use a code from the 401.x series (Essential hypertension) in addition to a code from the 593.x series (Other disorders of kidney and ureter) when you're coding a hypertension diagnosis caused by renal insufficiency, Conklin says. Instead, you'll need only one specific code.

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