ICD 10 and Nephrology
Jeff Kaufhold, MD FACP
Nephrology Associates of Dayton
Oct 2013
Make the Diagnosis of
Kidney Disease
• Criteria
The ICD9 Code for CKD is 585.x where x = stage
The ICD 9 Code for ARF is 584.9
 Decreased kidney function
eGFR of <60 ml/min/1.73 m2 for ≥ 3 months
 Abnormal urinalysis including the presence of
proteinuria or hematuria
 Request a spot urine protein/creatinine ratio
(Normal is <30 mg/g)
 Document an abnormal Renal Imaging Study
2
ICD 9 and 10 history
• ICD 9 developed by WHO
• ICD 9 Clinical Modification developed for US in 1979.
• CPT (clinical Procedural Terminology) codes used for
ambulatory reporting.
• ICD 10 developed in 1990’s
• ICD 10 codes are now available in EPIC as of Oct 1 2013
• Mandatory use of ICD 10 is Oct 1, 2014.
• CPT codes will continue to be used for physician
practice settings/ office billing
ICD 10 after Oct 1 2014
• Required for HIPAA transactions
• ICD 10 CM (Diagnosis) codes Required for
diagnosis of all services inpt or outpt
• ICD 10 PCS (procedure) codes will be required
on inpt claims
• EPIC is starting the migration from ICD 9 to 10
codes now, and EPIC Premier inpt billing
function includes the new ICD 10 coding
structure.
ICD 10 Changes
Over 50% of new Dx are musculoskel, and 36 % are to distinguish R from L
ICD 10 Changes
• Up to 7 characters
• Includes complication, severity, sequelae and
other disease related parameters
• Includes laterality
• Includes initial or subsequent encounter code
• Improved consistency of terminology
• Combination codes are common i.e DM 2,
controlled with renal manifestation
• Has space holders for expansion
ICD 10 PCS coding for inpts
0
D
B
5
8
Z
X
Section
Body
system
Root
operation
Body part
Approach
Device
qualifier
Med/Surg
GI
Excision
Esophagus Natural
No device
opening,
implanted
endoscopi
c
Diagnostic
ICD 9 ; 45.16 EGD with excisional biopsy,
ICD 10 0DB58ZX Endoscopic esophageal excision via natural or artificial opening
Most common issues in ICD 10
• Laterality – as you code, EPIC will prompt you
if right or left is required
• Trimester specific
• Many new orthopedic codes
• Specificity is increased dramatically, so
physician documentation must be more
specific too.
Top 5 Clinical Documentation Issues
•
•
•
•
•
CHF
Sepsis
Renal Failure
Pneumonia
Respiratory Failure
• Don’t use “Other” or accept a nonspecific
diagnosis like DM, when a more specific term
exists:
• “DM 2 controlled with renal manifestation”
ICD 10 codes
• Epic is migrating codes so over next year you
may search using known ICD 9 codes
• Can keep your PMHx and ongoing problem list
NONSPECIFIC,
• But your visit diagnosis list must be as specific,
detailed, and include as many modifiers/
comorbidities/severity codes as possible
Common Diagnoses
• ICD 9
• ICD 10
• 250.02 DM 2 no
mention of controlled
or complication
• E11.65 DM 2 with
hyperglycemia
• 250.43 DM 1 with renal
manifestation
• E10.21 DM 1 with
nephropathy AND
• E10.65 DM1 with
hyperglycemia
Top 5 Clinical Documentation issues
Condition
Common issues
Financial impact
CHF
Acute vs Chronic,
systolic vs diastolic
DRG 684 Renal failure
without major
complication or
comorbidity
Sepsis
Sepsis, severe sepsis, SIRS,
bacteremia
$ 3609
Renal Failure
Acute vs chronic
Stage with RIFLE criteria or
CKD stage
With ATN is important
DRG 682 renal failure with
major complication and
comorbidity
Pneumonia
Cause / specific bacteria
Aspiration, simple vs
complex, laterality
$ 9340
Respiratory Failure
Acute vs chronic, resp
distress vs resp failure
Quality Performance hinges on
Documentation
• For inpts affects the hospital quality score
• For our pts affects our practice score
• Lack of clear documentation results in
inappropriate assignment of complication codes
for expected consequence of renal disease
• Improved documentation results in lower
reported complication rates,
• higher complexity/ comorbidity scores reflect
sicker population we care for.
Specific details for pts
with ARF and CKD
• DM Type I or II, controlled or uncontrolled
– Use A1c over 6.5 as uncontrolled
– With renal manifestation
• Hypertension
– With nephropathy
• CKD stages 1-5, use ESRD for pts on dialysis in
the medicare ESRD program.
• AKI with ATN
Specific details for pts
with ARF and CKD
• AKI with ATN
–
–
–
–
Urine findings ATN casts
Oliguria
Creatinine over 2.5 or > 2X baseline
Were they pre-renal?
• Does pt have TIN?
• Complications of renal failure
– Anemia of CKD
– Secondary hyperparathyroidism of renal origin
– Protein calorie malnutrition Severe = albumin less
than 3.0
Estimated impact on physician practice
• 10 -20 % increase in denials
• Differences in authorization and referral
triggers
• Increased scrutiny of documentation
• Impact on contracting/ preferred provider
status based on severity of illness as reflected
in coding.
ICD 10 and EPIC
• ICD 10 diagnosis calculator goes live on
Premier Epic Oct 28 2013
• Training modules available on Healthstream
• Some codes require specific information, and
a coding window will open to fill in R vs L,
initial visit vs followup, sequelae.
• Many codes won’t require more specificity,
but for visits we should try to be as specific as
possible.
ICD 10 and EPIC
• Many codes won’t require more specificity,
but for visits we should try to be as specific as
possible.
• We can double click item on the problem list
like DM, HTN, Other disorder of renal etc, and
make it more specific, without losing /
deleting associations.
Diabetes codes
• E08.22 DM due to underlying condition with
diabetic nephropathy
• E09.22 Drug or chemical induced DM with
DM CKD
• E10.22 DM I with Diab. Neph
• E11.22 DM II with Diabetic Nephropathy
• E13.22 Other specified DM with Diabetic CKD
CKD Codes
•
•
•
•
•
•
•
N18.1 CKD stage 1
N18.2 CKD Stage 2
N18.3 CKD Stage 3
N18.4 CKD Stage 4
N18.5 CKD stage 5
N18.6 ESRD
N18.9 CKD unspecified
CKD and DM codes
• Code the DM first, then the stage:
– E10.22 Type I DM with nephropathy
– N18.6 ESRD
• Same for Hypertensive Kidney Disease
– I12 hypertensive Kidney disease
– N18.4 CKD Stage 4
– If pt has heart and kidney disease, use
• I13 hypertensive Heart and CKD
– CHF uses I 50 codes
HTN and CKD Codes
• I12.0 Hypertensive CKD with Stage 5 or ESRD
• I12.9 “” “” with stages 1-4 CKD
• I13.10 Hypertensive Heart and CKD without
heart failure, Stages 1-4
• I13.11 Hypertensive Heart and CKD without
heart failure, Stage 5 or ESRD
• I13.2 Hypertensive Heart and CKD with heart
failure, Stage 5 or ESRD
Nephrology Codes
•
•
•
•
•
•
•
N 0 – 8 Glomerulonephritis
N 10 Interstitial Nephritis
N 17 ARF
N 18 CKD
N 20 Kidney stone
N 30-39 Bladder disorders
N 40 BPH
– ICD10Data.com
Nephrology Codes
• PCKD Q 61.3
• Acquired cyst N 28.1
• Q 60-64 Congenital Malformations of the
urinary System
• R 80 Proteinuria
• R 81 Glycosuria
• R 60 Edema
– ICD10data.com
Nephrology Codes for ICD 10
• Electrolyte disorders: E 87
– High K E 87.5
• Protein Calorie Malnutrition
– E 43 severe
– E 44 Mild to Moderate
• Secondary hyperparathyroidism of renal origin
– N 25.81
Nephrology Common Codes
• Anemia of CKD D 63.1
• Lupus Nephritis
– SLE M 32 – not completely mapped yet
• Renal transplant – has not yet mapped
– (as of Oct 2013)
– Dysfunction would be coded with the ARF or CKD
code to denote pts renal function at time of visit
• N 17.9 ARF
• N 18.3 CKD stage 3
Transplant Specifics
• Just because your patient has a transplant,
they still have Chronic Kidney disease.
– List the transplant
– List the CKD stage for chronic allograft dysfunction
– List acute allograft dysfunction if present
– List the cause of their underlying CKD/ESRD
– List comorbidities and complications
• Are they anemic due to Cellcept use?
• Did they develop NODAT?
Doc talk, Precyse University, Oct 2013
PCKD specifics
• PCKD Q 61.3
• Acquired cyst N 28.1
• Q 60-64 Congenital Malformations of the
urinary System
• Autosomal Dominant or recessive?
• Liver /other cysts?