Mayrene Hernandez, DO
Advanced ProMed Inc.
Billing and Management Solutions
Board Certified in Family Medicine
Clinical Assistant Professor for NSU
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.
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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.
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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
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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.
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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
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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
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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
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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.
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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
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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
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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
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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.
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Summary: HTN with CKD
HTN with CKD
403 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 code
585.1-585.6
*most common
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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
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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.
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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).
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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)
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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.
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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
o
o
o
0. Type II unspecified if controlled (commonly used)
1. Type I unspecified if controlled
2. Type II uncontrolled
3. Type I uncontrolled
 The CKD stage must also be coded and specified
secondary.
 Use of long-term insulin should be coded (V58.67).
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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
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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
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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
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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 underdiagnosed.
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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 coexisting conditions.
 Refer to nephrologist as necessary: recommend
when GFR <30.
 Educate our patients and staff.
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References
1.
2.
3.
4.
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.
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.
Hart AC, Stegman MS, Ford B, eds. ICD-9-CM Expert for Hospitals. 6th ed. Ingenix;
2010: Vols. 1 & 2.
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.
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Thank You Kindly for Your Attention
Mayrene Hernandez, DO
Advanced ProMed Billing and
Management Solutions
ADVANCEDPROMED.COM
1-877-PRO-1MGT