Presentation on theme: "Lesley Stevens MD Tufts-New England Medical Center"— Presentation transcript:
1 Chronic Kidney Disease: Proposed Revisions to the ICD-9-CM Classification Lesley Stevens MDTufts-New England Medical CenterNational Kidney Foundation
2 Objectives Kidney Failure Stages of Chronic Kidney Disease Definition and Classification of CKDGFRProteinuriaEtiologyCurrent use of ICD-9-CM codes for CKDProposed changes to ICD-9-CM
3 Incidence and Prevalence of End-Stage Renal Disease in the US
4 Cardiovascular Mortality in the General Population and in ESRD Treated by Dialysis Annual mortality (%)100Dialysis10General population10.1MaleFemale0.01BlackWhite25–3435–4445–5455–6465–7475–8485Age (years)
5 Costs of Associated with Initiation of Dialysis St Peters, Khan, Ebben. Li, Xue, Pereira, Collins. Kidney Int. 200.
6 Stages in Progression of Chronic Kidney Disease and Therapeutic Strategies ComplicationsNormalIncreased riskDamage GFRKidney failureCKD deathScreening for CKD risk factorsCKD risk reduction; Screening for CKDDiagnosis & treatment; Treat comorbid conditions; Slow progressionEstimate progression; Treat complications; Prepare for replacementReplacement by dialysis & transplant
7 Definition of CKDStructural or functional abnormalities of the kidneys for >3 months, as manifested by either:1. Kidney damage, with or without decreased GFR, as defined bypathologic abnormalitiesmarkers of kidney damage, including abnormalities in the composition of the blood or urine or abnormalities in imaging tests2. GFR <60 ml/min/1.73 m2, with or without kidney damage
8 Prevalence of CKD and Estimated Number of Adults with CKD in the US (NHANES 88-94) StageDescriptionGFR(ml/min/1.73 m2)Prevalence*N (1000s)%1Kidney Damage with Normal or GFR 905,9003.32Kidney Damage with Mild GFR60-895,3003.03Moderate GFR30-597,6004.34Severe GFR15-294000.25Kidney Failure< 15 or Dialysis3000.1*Stages 1-4 from NHANES III ( ). Population of 177 million with age 20. Stage 5 from USRDS (1998), includes approximately 230,000 patients treated by dialysis, and assuming 70,000 additional patients not on dialysis. GFR estimated from serum creatinine using MDRD Study equation based on age, gender, race and calibration for serum creatinine. For Stage 1 and 2, kidney damage estimated by spot albumin-to-creatinine ratio 17 mg/g in men or 25 mg/g in women in two measurements.
9 Prevalence of Abnormalities at each level of GFR *>140/90 or antihypertensive medicationp-trend < for each abnormality
10 Age-Standardized Rates of Death from Any Cause (Panel A) and Cardiovascular Events (Panel B), According to the Estimated GFR among 1,120,295 Ambulatory AdultsGo, A, et al. NEJM 351: 1296
11 Clinical Practice Guidelines for the Detection, Evaluation and Management of CKD
12 Definition of ESRD vs Kidney Failure ESRD is a federal government defined term that indicates chronic treatment by dialysis or transplantationKidney Failure: GFR < 15 ml/min/1.73 m2 or on dialysis.
14 Albuminuria as a Risk Factor for CVD in PREVEND Hillege HL et al. Circulation 2002: 106:
15 Progression of Kidney Disease related to level of proteinuria and blood pressure lowering in MDRD StudyPetersen. Annals of Internal Medicine. 1995
16 Clinical Practice Guidelines for Management of Hypertension in CKD Type of Kidney DiseaseBlood Pressure Target(mm Hg)Preferred Agents for CKD, with or without HypertensionOther Agents to Reduce CVD Risk and Reach Blood Pressure TargetDiabetic Kidney Disease<130/80ACE inhibitor or ARBDiuretic preferred, then BB or CCBNondiabetic Kidney Disease with Urine Total Protein-to-Creatinine Ratio 200 mg/gNondiabetic Kidney Disease with Spot Urine Total Protein-to-Creatinine ratio <200 mg/gNone preferredDiuretic preferred, then ACE inhibitor, ARB, BB or CCBKidney Disease in Kidney Transplant RecipientCCB, diuretic, BB, ACE inhibitor, ARB
17 Classification of CKD by Diagnosis Diabetic Kidney DiseaseGlomerular diseases (autoimmune diseases, systemic infections, drugs, neoplasia)Vascular diseases (renal artery disease, hypertension, microangiopathy)Tubulointerstitial diseases (urinary tract infection, stones, obstruction, drug toxicity)Cystic diseases (polycystic kidney disease)Diseases in the transplant (Allograft nephropathy, drug toxicity, recurrent diseases, transplant glomerulopathy)
18 Current use of ICD-9-CM codes for Kidney Disease ICD-9-CM codes for kidney disease were used in 1% of all patients.* GFR in ml/min/1.72 m2
19 Current use of ‘585’ (chronic renal failure) in 277, 262 adults visiting an outpatient commercial clinical laboratoryGFR (ml/min/1.73 m2)*>9060-8930-5915-29<15No 585 code**1360273<1585 code1062232* GFR in ml/min/1.72 m2**Row Percentages
21 Proposed Classification: CKD code 586.1 Stage I CKD: Kidney damage with normal or increased glomerular filtration rate (GFR), greater than or equal to 90 ml/min/1.73m2586.2 Stage II CKD: Kidney damage with mild decrease in GFR ml/min/1.73m2586.3 Stage III CKD: Kidney damage with moderate decrease in GFR ml/min/1.73m2586.4 Stage IV CKD: Kidney damage with severe decrease in GFR ml/min/1.73m2586.5 Stage V CKD: Kidney damage with GFR of less than 15 ml/min/1.73m2 Kidney failure with GFR less than 15 ml/min/1.73m2 and not on dialysisNote: Codes apply only to patients diagnosed kidney disease > 3 mo
22 Proposed Classification: CKD code 5th digit Each 586 (CKD) code requires a 5th digit to indicate evidence of proteinuria or albuminuria586.X0 for those without evidence of proteinuria or albuminuria586.X1 for those with evidence of proteinuria or albuminuria
23 Proposed Classification: Etiology Instructions to code for CKD stage along with disease specific codes250.4 Diabetes with renal manifestationsUse additional code to identify manifestation, as: Add chronic kidney disease ( )Chronic glomerulonephritis in diseases classified elsewhere: amyloidosis, SLE
24 Benefits of Revised ICD-9-CM codes Distinguish between ESRD and CKD; between dialysis and transplantationAssess risk for adverse outcomes, expected complications and comorbid disease by the combination of severity of CKD (stages), proteinuria and diagnosisDetermine which patients require specific treatments based on severity of CKD, and in particular proteinuriaExamine of health care utilization and costs. Assess rural and urban settings and racial disparitiesAssess quality of care deliveredProgress toward achievement of Healthy People goalsAllow CMS and USRDS to develop specific research files to investigators to enhance our knowledge of CKD by the major risk groups