Wiki Coding the GFR

[pkb1969]

As a coding rule, coders cannot code the stage of Chronic Kidney Disease unless it is documented in the note. I have a dilemna. The GFR is documented in the note as 31, but the Dr. used the common Chronic Kidney Disease Code for the diagnosis instead of a more specific code to show the stage. Am I allowed to change this code since it states in the note as the GFR to be 31??

 

[mitchellde]

No in this case the stage must be documented. You can request the provider addend the note before you submit the claim so that it can be coded . However coders are not to interpret results for a diagnosis.