ICD 10 and Nephrology
How to find ARF and CKD
For Coders and Clinical
Documentation Specialists
Jeff Kaufhold MD FACP
Nephrology Associates of Dayton
Oct 2013
Summary
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Review of the development of ICD 10
Changes coming with ICD 10
Top 5 Clinical Documentation Issues
Making the Diagnosis of ARF and CKD
ICD 10 codes for renal disease
RIFLE criteria for Acute renal Failure
Progression of CKD and CKD stages
How to differentiate Acute from Chronic
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
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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.
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.
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
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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
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Urine findings ATN casts
Oliguria
Creatinine over 2.5 or > 2X baseline
Were they pre-renal?
• Does pt have TIN?
• Look for eosinophils in blood or urine
• Complications of renal failure
– Anemia of CKD
– Secondary hyperparathyroidism of renal origin
– Protein calorie malnutrition Severe = albumin less than 3.0
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
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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
The Early NHANES III Study
Analysis of Prevalence of CKD by Stage
eGFR Range
Population
(1,000’s)
Population
(%)
Stage
Description
1
Kidney
damage with
normal or
increase GFR
≥ 90
5,900
3.3 %
2
Mildly
decreased
GFR
60-89
5,300
3.0 %
3
Moderately
decreased
GFR
30-59
7,600
4.3 %
4
Severely
decreased
GFR
15-29
400
0.2 %
5
Kidney Failure
< 15
300
0.1%
(ml/min/ 1.73 m2)
- Adapted from NHANES III (2000)
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US Population with CKD
Coresh, Selvin, Stevens. Prevalence of CKD in the US. JAMA.2007;298(17)2038.
A Large National Burden in 2009
The Renal Continuum of Care
Primary Care
Physician
At Risk
Population
Diabetes
Hypertension
Obesity
CVD
Nephrologist
CKD
ESRD
500,000+ People
~375,000 Dialysis
26,000,000+ People
~125,000 Transplant
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Cardiovascular events by Stage of CKD
NKF KDOQI guidelines www.kidney.org/professionals/KDOQI/guidelines_ckd/toc.htm
All Cause Mortality By Stage of CKD
NKF KDOQI guidelines www.kidney.org/professionals/KDOQI/guidelines_ckd/toc.htm
Why Do CKD Patients Need Special Care?
Renal Disease Care is Expensive
~1.5% of Patients
~10% of Federal Healthcare Costs
ESRD + Late Stage
Chronic Kidney
Disease (CKD)
Other
Medicare
~ $30B per
year
Other
Medicare
Source: USRDS (publicly available comprehensive clinical and financial dataset reported to and used by CMS)
~375,000 ESRD + ~300,000 Stage 4 Chronic Kidney Disease
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Timely Referral: Long-lasting benefits
Late Referral patients have a 44% higher risk
of mortality in the first year of dialysis
compared to Early Referral patients
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Who Should be Screened for CKD?
The AT RISK Population:
– HYPERTENSION
– DIABETES MELLITUS
– CARDIOVASCULAR DISEASE
– FAMILY HISTORY OF CKD
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Screening Recommendations
• Screening Should Include:
– Laboratory studies to include serum creatinine
and eGFR
– Urinalysis to determine the presence of
proteinuria
– Imaging studies such as ultrasound
Screening recommendations are provided in
KDOQI, Guideline 1
http://www.kidney.org/professionals/kdoqi/guidelines_ckd/toc.htm
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Presence of MAU Indicates a Potential
Increased Risk for CV Events
Urinary Albumin (mg/day)
1,000
900
Macroalbuminuria
>300 mg/day
Increased CV Risk and Presence of
Renal and Vascular Dysfunction
800
700
600
500
400
300
200
100
MAU
30-299 mg/day
Increased CV Risk
and Vascular
Dysfunction
0
Normal
Cardiovascular Risk
Garg JP et al. Vasc Med. 2002;7:35-43. Eknoyan G et al. Am J Kidney Dis. 2003;42:617-622.
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
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How to Implement Timely Referral?
• Establish CKD diagnosis and Details:
– Make a specific renal disease diagnosis if possible
– Identify co-morbidities
• Hypertension
• Diabetes
• Cardiovascular Disease
– Determine the severity of CKD (know the eGFR)
– Identify CKD Complications
• Anemia (know the Hgb)
• Secondary Hyperparathyroidism (know the Ca and Phos)
• Malnutrition (know the albumin)
– Assess stability of Kidney Function and CKD Stage
Recommendations for further evaluation are outlined in KDOQI Guideline 2
http://www.kidney.org/professionals/kdoqi/guidelines_ckd/toc.htm
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Timely Referral Decision Making
• Timely Referral Guidance:
– Rapidly decreasing renal function REFER
– Abnormal eGFR AND proteinuria  REFER
– eGFR ≤ 30 ml/min/ 1.73 m2  REFER
– eGFR <60 ml/min/1.73 m2 and Cardiovascular Disease
Present  REFER
– Uncontrolled Hypertension Present  REFER
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Reason for Nephrology Consultation
in the Hospitalized patient
25%
ARF
15%
Fluid & Lytes
Other
60%
Ref: Paller Sem Neph 1998, 18(5), 524.
Acute Dialysis Quality Initiative
• RIFLE Criteria Helps risk stratify patients with
acute renal failure.
• Increased mortality seen with increases in
creatinine of 0.3 to 0.5 mg/dl
– 70 % increase for all inpts,
– 300 % increase in cardiac surgery pts
Acute Renal Failure
• Definition may depend on whom you ask
– Surgeon - - low urine output
– Intensivist-- severe acidemia
– Nephrologist-- rising serum creatinine
• Frequency - depends on clinical setting
– 1% of all admissions to hospital
– 2-5% of all individuals during a hospitalization
– 4-15% during cardiopulmonary bypass
– 10-30% of all admissions to ICU
Definition
• ‘…a sudden and severe decrease in
the glomerular filtration rate (GFR)
sufficient to cause increases in BUN
and Scr (azotemia), Na/H2O retention
(edema), and development of
acidemia and hyperkalemia…’
• review of 27 studies showed no 2 used
the same definition “chronic renal
confusion”
What’s in a name?
• lack of a universally recognized
definition of ARF
• 2004 consensus conference
– proposed the term acute kidney injury
(AKI) to reflect the entire spectrum of ARF
recognizing that an acute decline in
kidney function is often secondary to an
injury that causes functional or structural
changes in the kidneys
Newest Definition:
Mehta CritCare 2007
• An abrupt (within 48 h) reduction in
kidney function currently defined as:
– an absolute increase in serum creatinine
of either >= 0.3 mg/dl,
– or a percentage increase of >= 50 % or a
reduction in UOP (documented oliguria of
< 0.5 ml/kg per h for > 6)
RIFLE criteria
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Risk low uop for 6 hours, creat up 1.5 to 2 times baseline
Injury creat up 2 to 3 times baseline, low uop for 12 hours
Failure Creat up > 3 times baseline or over 4, anuria
Loss of Function Dialysis requiring for > 4 weeks
ESRD Dialysis requiring for > 3 months
RIFLE estimate of Mortality
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Two studies
No renal failure
Risk
Injury
Failure
Loss of Function
ESRD
Uchino
4.4 %
15%
29%
53.9%
Hoste
5.5
8.8
11.4
26%
Crit Care Med 2006; 34:1913-7, Hoste CCM 2006; 10:R73
RIFLE criteria
• When markers of severity of illness are looked
at excluding renal data, no difference in
groups is seen.
The differential for any lab
abnormality is:
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Lab error
Lab error
Lab error
Iatrogenic
Polypharmacy
Real disease
IN THIS ORDER!
Acute renal failure (ARF)
• Differential for Lab abnormality: Causes:
– A rise in the BUN level can occur without renal
injury, such as in GI or mucosal bleeding, steroid
use, or protein loading (such as IV nutrition)
– A rise in the creatinine level can result from
medications (eg, cimetidine, trimethoprim) that
inhibit the kidney’s tubular secretion, or an
increase in creatinine production such as seen in
Rhabdomyolysis. (muscle breakdown)
– True Anuria is most commonly the result of an
obstructed foley catheter, or an error in recording
output. The worst cause of anuria is cortical
necrosis.
Acute renal failure (ARF)
• An abrupt or rapid decline in renal
function
• Marked by a rise in BUN (azotemia) or
serum creatinine concentration
– Immediately after a kidney injury, BUN or
creatinine levels may be normal
• The only sign of a kidney injury may be
decreased urine production
• Use RIFLE Criteria to evaluate Risk.
Acute renal failure (ARF)
• History and Physical examination:
– Nephrotoxic drug ingestion
– History of trauma or unaccustomed exertion
– Blood loss or transfusions
– Congestive heart failure
– Exposure to toxic substances, such as ethyl
alcohol or ethylene glycol
Acute renal failure (ARF)
• History and Physical examination:
– Exposure to mercury vapors, lead, cadmium,
or other heavy metals, which can be
encountered in welders and miners
– Hypotension
– Volume contraction
• Vomiting/Diarrhea/Sweating/Nursing Home
– Evidence of connective tissue disorders or
autoimmune diseases
Pathophysiology
• ARF may occur in 3 clinical patterns
BUN:Cr > 20:1
BUN:Cr 10-20:1
BUN:Cr > 20:1
Pathophysiology
• ARF may occur in 3 clinical patterns
• Suggested by labwork:
BUN:Cr > 20:1
Pre-Renal or Post-Renal
BUN:Cr 10-20:1 Intra-Renal
BUN:Cr < 10:1
Extrinsic Production of Creatinine
(rhabdomyolysis),
this pattern also seen in dialysis patients)
Prerenal ARF
• Prerenal ARF represents the most common form of
kidney injury and often leads to intrinsic ARF if it is
not promptly corrected
• From any form of extreme volume loss
– GI, renal (Vomiting, Diarrhea, diuretics, polyuria),
cutaneous (eg, burns), and internal or external
hemorrhage can result in this syndrome
• Systemic vasodilation or decreased renal perfusion
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Anesthetics
Drug overdose
Heart failure
Shock (eg, sepsis, anaphylaxis)
Approach to ARF
• Pre-Renal
– Most common
– Due to NPO, Diuretics, ACE inhibitors,
NSAIDS
– Due to renal artery disease, CHF with poor
EF.
– Usually BUN / creat ratio over 20.
– Usually creat < 2.5
Approach to ARF
• Intra-Renal
– Most commonly pre-renal tipping over
into true renal injury.
– Acute Tubular Necrosis is result (70%)
– Tubulo-Interstitial Nephritis (20%)
– Acute vasculitis/GN rare (5-10 %)
Intrinsic Renal Failure
• Intrinsic ARF
– acute tubular necrosis
– acute interstitial nephritis
– acute glomerulonephritis
– acute vascular syndromes
– intratubular obstruction
• BUN:Creat ratio 10-20 :1
• In Pre-renal ARF, once creat is > 2.5,
there is some degree of ATN
Intrinsic ARF
Urinalysis
• Intra-Renal
– Acute Tubular Necrosis (70%)
• Dirty brown casts, low UOP
– Tubulo-Interstitial Nephritis (20%)
• Eosinophils in blood or urine,
• Potassium out of proportion to creat.
• Normal BP, related to drug exposure
– Acute vasculitis/GN rare (5-10 %)
• Proteinuria, hematuria, RBC casts
Approach to ARF
• Post- Renal
– Most commonly due to obstruction at
bladder outlet
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Prostate problems
Neurogenic bladder
Stone
Urethral stricture (esp after CABG)
Acute Renal failure
Complications of acute renal failure
Hyperkalemia ( ECG abnormalities)
Decreased bicarbonate (acidosis)
Elevated urea
Elevated creatinine
Elevated uric acid
Hypocalcaemia
Hyperphosphatemia
Accumulation and toxicity of medications
secreted by the kidney
Documentation for ARF
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List the ARF
N17.9
Cause of the ARF (ATN N17.0)
Underlying CKD with stage if present N18.X
Volume status
– Volume overloaded E 87.7 or dry E 86
• Electrolyte abnormalities
– Hyperkalemia E 87.5 / hyponatremia E 87.1
• Acid base status – acidosis E 87.2 or alkalosis E 87.3
• Estimated GFR: < 30 ml/min means many meds need to be
adjusted
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?
One common Cause of ARF
• Contrast Induced nephropathy CIN
Risk Factors for Contrast Nephropathy
• Age over 60
• Diabetes
• Pre-Renal States
– CHF
– NSAIDS, ACE Inhibitors, Diuretics
• Proteinuria Includes, but not limited to
Myeloma.
• Pre-existing Renal Disease
Risk of CN By Stage of CKD
100
90
80
70
60
Dialysis
ARF
50
40
30
20
10
0
Stg 5
< 20 ml/min
Stg 4
20 – 30
Stg 3
30 – 60
Stg 2
> 60
CKD Stages
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•
•
•
•
Stage 1.
Stage 2.
Stage 3.
Stage 4.
Stage 5.
Stage 6.
Normal function with known dz
GFR 60-80
GFR 30-60
GFR 15-30.
GFR less than 15.
ESRD on dialysis.
Progression of CRF
80
70
60
50
40
GFR
30
20
10
0
PTH climbs PO4 rising K, Urate Up Anemia Sx
How do you differentiate ARF
from CRF.
• What physical exam finding tells you
the pt has Chronic Kidney Disease?
• What Would you see on renal Imaging
for a pt with CKD?
Lindsey’s Nails
Acute vs Chronic Renal Failure
Atrophic Kidney on CT