1. Mayrene Hernandez, DO Advanced ProMed Inc. Billing and Management Solutions Board Certified in Family Medicine Clinical Assistant Professor for NSU

2. Chronic Kidney Disease Webinar Objectives Identify correct coding practices for Chronic Kidney Disease (CKD) staging utilizing GFR calculations and how to code for renal complications of severe and advanced CKD. Discuss proper ICD-9-CM coding when CKD co- exists with hypertension, CHF and diabetes. Discuss how ICD-9-CM coding can help to allocate possible future funds to prevent CKD and increase public awareness. 2

3. CKD CKD, also known as chronic renal insufficiency (CRI), is a progressive loss of renal function over a period of months or years and divided into five stages. Each stage is divided into ranges of declining glomerular filtration rate (GFR) or, which is usually determined indirectly by the creatinine level in blood serum. We can also measure early findings of CKD utilizing microalbumin levels chronically elevated in the urine, acquired randomly or in a 24-hour urine collection. 3

4. GFR Calculations GFR calculations, which are now readily available via laboratory reports, are calculated for physicians and can be utilized to code CKD into stages. Formula for GFR calculation (m/min/1.73m2) CKD divided into stages I through V 4

5. Coding CKD Stage I CKD Stage I GFR may be >90 (>60 reported) Usually other clinical asymptomatic markers of kidney disease co-exist. Most commonly, chronic microalbuminuria. Microalbumin levels can be readily diagnosed utilizing random urine samples. ICD-9-CM codes: o 585.1 CKD Stage I o Microalbuminuria 791.0 Current laboratory calculations also take into account African-American descent and female and male ratio. They do not account for age or nephrotoxic agents, which can also impair GFR. 5

6. Coding CKD Stage II CKD GFR Stage II range 60-89 This stage is also classified or known as mild CKD. Complications of CKD with co-morbid conditions are usually also mild. ICD-9-CM codes: o 585.2 CKD Stage II; microalbuminuria should also be coded if found in the urine. o Microalbuminuria 791.0 6

7. Coding CKD Stage III CKD Stage III GFR range 30-59 This stage is also known as moderate CKD. Complications with co-morbid conditions are usually moderate. ICD-9-CM codes: o 585.3 CKD Stage III o Microalbuminuria 791.0 if co-existing 7

8. Coding CKD Stage IV CKD Stage IV GFR range 15-29 This is also known as severe CKD. Complications are usually severe and patients need to be prepared for impending dialysis, i.e., mapping, permanent access placement, AVF. Other complications of renal disease need to be coded when found during this stage. ICD-9-CM codes: o 585.4 CKD Stage IV o Microalbuminuria 791.0 8

9. Coding CKD Stage V CKD Stage V GFR <15 This stage is also known as chronic kidney failure but does not include dialysis status or end stage renal disease (ESRD). ICD-9-CM codes: o 585.5 CKD Stage V Code for all existing complications of renal disease including microalbuminuria. These codes help stratify and document the difficulties of the advanced stage CKD patient. 9

10. Coding for ESRD GFR <15 on dialysis status This stage implies ESRD with need for dialysis. The dialysis status should also be coded. ICD-9-CM codes: o 585.6 (ESRD on dialysis) Dialysis Status V45.11 10

11. Coding Stages of CKD Summary CKD Stage I GFR >90 CKD Stage II GFR 60-89 CKD Stage III GFR 30-59 CKD Stage IV GFR 15-29 CKD Stage V GFR <15 CKD ESRD on Dialysis Microalbuminuria Dialysis status 585.1 585.2 585.3 585.4 585.5 585.6 791.0 V45.11 11

12. Coding for Complications Complications of severe to advanced renal disease may include, but not be limited to, the following electrolyte disturbances and other co-morbid conditions: Hyperkalemia 276.7 Secondary hyperparathyroidism 588.81 Anemia of chronic illness 285.2 Renal osteodystrophy 588.0 Uric acid elevations 790.6 12

13. Coding CKD and Hypertension When CKD co-exists with hypertension (HTN), the code used to document HTN should be coded differently than the commonly utilized code for essential HTN 401.9. The following code ranges should be utilized when coding HTN and CKD: 403.0-403.9. A fourth digit identifies benign or malignant hypertensive disease, and a fifth digit is added to state if CKD Stage is I through IV or if HTN co-exists with ESRD. 13

14. 14 Summary: HTN with CKD HTN with CKD403 category Fourth digit required: o Malignant HTN 403.0 ( ) fourth digit o Benign HTN 403.1 ( )*fourth digit Fifth digit needed to state o Stages I-V or 0 o ESRD 1 Addition of CKD stage code585.1-585.6 *most common

15. HTN and CKD Example Coding for hypertensive CKD with CKD Stage II is common. ICD-9-CM Codes: o 403.10 Hypertensive benign CKD o 585.2 CKD Stage II o 791.0 for microalbuminuria, if present 15

16. HTN with Congestive Heart Failure and CKD When HTN co-exists with congestive heart failure (CHF) and CKD, the following diagnosis codes should be used: o 404 Code Category hypertensive heart and CKD o Fourth digit categorizes benign or malignant type of hypertension. o Fifth digit identifies if found with existing CHF or without. o Additional codes for CKD stage and also types of CHF (diastolic/systolic/right- and left-sided) also need to be added. 16

17. HTN with CHF and CKD 404 hypertensive heart and CKD Fourth digits: o 404.0 Malignant fourth digit o 404.1 Benign (most common) Fifth digit needed: o 404.10 No CHF, with CKD I-IV o 404.11 Co-existing with CHF and CKD I-IV o 404.12 No CHF, with CKD Stage V/ESRD o 404.13 Co-existing with CHF and CKD Stage V/ESRD o Different types of heart failure (428.0 - 428.43). 17

18. HTN with CHF and CKD Example Hypertensive heart benign with CHF and CKD Stage III would be coded. ICD-9-CM Codes: o 404.11 Hypertensive heart with CKD o 585.3 CKD Stage III o 428.0 CHF* When CHF exists with HTN without CKD, code as 402.11 (usually not coded properly--coded 401.9 and 428.0) 18

19. Coding CKD and Diabetes Type II When coding CKD and diabetes type II (DM II), if the origin of the CKD is excluded from other disease processes, then CKD can be considered as a diabetic manifestation (i.e., lupus and CKD that was present prior to DM II would be an exemption). Diabetes needs to be coded first, then the renal manifestations and the CKD staging for this condition. This also applies when co-existing with hypertension and diabetes. If the provider cannot find evidence of which disease process has affected kidney function first (diabetes or the hypertension), both conditions and complications are coded. 19

20. Coding CKD and Diabetes Type II ICD-9-CM code 250.4 DM II and CKD A fifth digit must be utilized to inform if diabetes type II involved, and if controlled or uncontrolled. 250.4 DM II with renal manifestation: The fifth digit includes o 0. Type II unspecified if controlled (commonly used) o 1. Type I unspecified if controlled o 2. Type II uncontrolled o 3. Type I uncontrolled The CKD stage must also be coded and specified secondary. Use of long-term insulin should be coded (V58.67). 20

21. Coding CKD and Diabetes Type II Example Coding for a diabetic type II patient with CKD Stage II would be as follows: ICD-9-CM: o 250.40 DM II with CKD o 585.2 CKD II o 791.0 with microalbuminuria, if present 21

22. Coding HTN and DM II with CKD Example Coding for a patient who is hypertensive and has DM II with CKD Stage II would be as follows: ICD-9-CM: o 403.10 HTN with CKD o 250.40 DM II with CKD o 585.2 CKD Stage II o If utilizing insulin, add V58.67 o If microalbuminuria, add 791.0 22

23. Coding CKD with Multiple Chronic Conditions Example of our common geriatric patient: HTN with CKD, DM II with CKD, CKD Stage III, and CHF The following ICD-9-CM codes apply: o 404.11 HTN with CHF and CKD o 428.0 CHF type (right- and left-sided) o 250.40 DM II with CKD o 585.3 CKD Stage III 23

24. Coding CKD Practices Coding from the physician’s perspective can help document the severity of illness in our patients. Utilizing proper coding and documentation techniques can also make an impact in our reimbursement calculation process. Coding properly can make a difference for everyone--the doctor and the patient. Provider awareness and education are important and necessary for disease prevention. CKD is on the rise…. and commonly under- diagnosed. 24

25. Coding CKD Practices What can we do? Determine the risk for CKD in our patients. Test and look for early signs of CKD. Follow GFR staging for proper coding techniques. Code properly for CKD with its complications and co- existing conditions. Refer to nephrologist as necessary: recommend when GFR <30. Educate our patients and staff. 25

26. References 1. Centers for Medicare & Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. Available at: http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf. Accessed March 17, 2010. 2. Gorman JK. Medicare+Choice risk adjustment: Don't leave money on the table – analysis of principal inpatient diagnostic cost group methodology. Healthcare Financial Management. August 2001. 3. Hart AC, Stegman MS, Ford B, eds. ICD-9-CM Expert for Hospitals. 6 th ed. Ingenix; 2010: Vols. 1 & 2. 4. Pope GC, Kautter J, Ellis RP, et al. Risk adjustment of Medicare capitation payments using the CMS-HCC model. Health Care Financing Review. Summer 2004;25:119-141. 26

27. Thank You Kindly for Your Attention Mayrene Hernandez, DO Advanced ProMed Billing and Management Solutions ADVANCEDPROMED.COM 1-877-PRO-1MGT