A patient presents herself today for a follow-up for her hypertension. At the last visit, she was complaining of swelling in her feet and ankles, back pain, trouble sleeping, and having to get up at night to urinate. She has a family history of CKD. She presents herself today for results of her GFR test.
ROS: As above, otherwise negative.
PFSH: As above. She does not drink or smoke.
Her GFR was 50. We discussed the fact that she is at stage 3 CKD. We discussed a referral to the nephrology department for recommendations and a treatment plan. She is positive about her diagnosis as she has had family members with CKD that take care of themselves and function very well. She wants to see the nephrologist as soon as possible. Calls were made to his office today and an appointment was made for her before she left our office. Dr. Jones will send me back his recommendations and we will move forward from there.
ASSESSMENT: Hypertension. CKD, stage 3.
The visit today was strictly counseling and coordinating care and a total face-to-face time of 40 minutes was spent with the patient discussing her condition, prognosis, outcomes, and referral to nephrology.
ICD-10-CM Codes:
I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
N18.3 Chronic kidney disease, stage 3
Rationale: According to the 2012 ICD-10-CM Official Guidelines/Reporting (C.9.a.2) assign codes from category I12 when both hypertension and a condition classifiable to category N18, Chronic kidney disease (CKD) are present. Unlike hypertension with heart disease, ICD-10-CM presumes a cause-and-effect relationship and classifies CKD with hypertension as hypertensive chronic kidney disease. The appropriate code from category N18 should be used as a secondary code with a code from category I12 to identify the stage of chronic kidney disease.
NOTE: The GFR test measures how well your kidneys are filtering a waste called creatinine, which is produced by the muscles. When the kidneys aren’t working as well as they should, creatinine builds up in the blood. Levels below 60 mL/min/1.73 m2 for 3 or more months are a sign of chronic kidney disease.


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