Filter Out Bad ESRD Coding
Use severity, condition, classification, and sequencing to help clean up your claims.
By Michelle A. Green, MPS, RHIA, CPC, FAHIMA
End stage renal disease (ESRD) is the most severe form of chronic kidney disease (CKD). At this stage, kidney function is so impaired that patients must receive regular hemodialysis to remove waste from the body, or undergo a kidney transplant.
ESRD patients undergo hemodialysis in an outpatient dialysis facility several times each week where waste products (e.g., creatinine, urea) are removed from their blood. Acutely ill ESRD patients may require inpatient admission during which hemodialysis is performed,and sometimes a kidney transplant is performed.
In contrast, many CKD patients perform their own peritoneal dialysis at home or elsewhere because the patient’s peritoneum is used as a membrane for the exchange of fluids and dissolved substances (e.g., electrolytes, urea, glucose) in their blood.
ICD-9-CM classifies CKD to category 585. A required fourth digit indicates the severity of the condition, as defined by the patient’s glomerular filtration rate (GFR):
585.1 Stage I: GFR > 90 mL/min/1.73 m2
585.2 Stage II: GFR 60-89 mL/min/1.73 m2
585.3 Stage III: GFR 30-59 mL/min/1.73 m2
585.4 Stage IV: GFR 15-29 mL/min/1.73 m2
585.5 Stage V: GFR < 15 mL/min/1.73 m2
585.6 End stage renal disease (ESRD): GFR < 15 mL/min/1.73 m2, and the patient is on dialysis or undergoing kidney transplant
According to the ICD-9-CM Official Guidelines for Coding and Reporting, if a patient is documented as having both CKD and ESRD, report only the ESRD (585.6).
Sequence ESRD Diagnoses with Care
Patients with ESRD (and other stages of CKD) often suffer other serious conditions, such as hypertension, diabetes mellitus, anemia, and transplant complications. Be careful to sequence these conditions properly when assigning ICD-9-CM codes.
To illustrate this point, consider the following:
Diabetes: Section I.C.3.a.4 of the ICD-9-CM guidelines specifies, “When assigning codes for diabetes and its associated conditions, the code(s) from the category 250 must be sequenced before the codes for the associated conditions … Assign as many codes from category 250 as needed to identify all of the associated conditions that the patient has.”
For example, a patient with type II diabetic ESRD presents to his physician’s office for a follow-up visit. There is no indication that the diabetes is uncontrolled. The diagnosis codes are assigned and sequenced in the following order:
250.40 Diabetes with renal manifestations; type II or unspecified type, not stated as uncontrolled
Anemia: Section I.C.4.a.1 of the ICD-9-CM guidelines states, “When assigning code 285.21, Anemia in chronic kidney disease, it is also necessary to assign a code from category 585, Chronic kidney disease, to indicate the stage of chronic kidney disease.” Whichever condition is the reason for the encounter should be sequenced first.
For example, if anemia is the reason for an encounter with a patient diagnosed with “anemia in end stage renal disease,” report:
285.21 Anemia in chronic kidney disease
Hypertensive CKD: Section I.C.7.a.3 of the ICD-9-CM guidelines instructs, “Assign codes from category 403, Hypertensive chronic kidney disease, when conditions classified to categories 585 or code 587 are present with hypertension … The appropriate code from category 585, Chronic kidney disease, should be used as a secondary code with a code from category 403 to identify the stage of chronic kidney disease.” When reported with 585.6, subcategory code 403.0 should include fifth-digit “1” (e.g., 403.01 Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease). Again, the reason for the encounter should be sequenced first.
Kidney transplant complications: Section I.C.17.f.2.b of the ICD-9-CM guidelines specifies, “A transplant complication code is only assigned if the complication affects the function of the transplanted organ. Two codes are required to fully describe a transplant complication, the appropriate code from subcategory 996.8 and a secondary code that identifies the complication.”
Patients who undergo a kidney transplant still may have CKD because the kidneys are not restored to full function. Do not assume that a patient who has had a kidney transplant and CKD developed the CKD because of the transplant. Select the code to report the stage of CKD and V42.0 Organ or tissue replaced by transplant; kidney to report kidney transplant status. Per the ICD-9-CM guidelines (I.C.17.f.2.a), “If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider.”
Dialysis Coding Varies by Location
Proper physician coding for dialysis services related to ESRD depends on place of service (POS).
Inpatient ESRD services, including all evaluation and management (E/M) services related to the patient’s renal disease, are reported using CPT® codes 90935-90937. According to CPT®, “Code 90935 is reported if only one evaluation of the patient is required related to that hemodialysis procedure. Code 90937 is reported when patient re-evaluation(s) is required during a hemodialysis procedure.”
Outpatient ESRD services may be reported per month (defined by CPT® as 30 days), according to the patient’s age:
- Younger than 2 years of age – 90951-90953
- 2-11 years of age – 90954-90956
- 12-19 years of age – 90957-90959
- 20 years of age or older – 90960-90962
These CPT® codes also account for the number of face-to-face physician visits with the patient each month. For example, a 10-year-old patient who meets face to face with the physician two times in a month would be reported as 90955 End-stage renal disease (ESRD) related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2-3 face-to-face physician visits per month. If the same patient meets with the physician five times in the same month, the correct code would be 90954 End-stage renal disease (ESRD) related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per month.
Per CPT® guidelines, 90951-90962 may be reported only once per month, and “include establishment of a dialyzing cycle, outpatient evaluation and management of the dialysis visits, telephone calls, and patient management during the dialysis provided during a full month.”
In-home ESRD services also are reported per month, according to patient age:
- Younger than 2 years of age – 90963
- 2- 11 years of age – 90964
- 12-19 years of age – 90965
- 20 years of age or older – 90966
Partial Month Services Call for Different Coding
If the patient has had a complete assessment visit “and services are provided over a period of less than a month, 90951-90962 may be used according to the number of visits performed,” per CPT®. For instance, a 30-year-old patient receives face-to-face ESRD-related services, including a complete evaluation, on a single occasion. In this case, report 90962 End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 1 face-to-face physician visit per month.
By contrast, “per day” codes 90967-90970 describe ESRD services for less than a full month of service when provided to:
- Partial month outpatients, where there was one or more face-to-face visits without the complete assessment
- Partial month home dialysis patients
- Transient patients
- A patient hospitalized before a complete assessment was furnished
- Patients for whom dialysis was stopped due to recovery, death, or kidney transplant
Per day codes 90967-90970 also are age-specific:
- Younger than 2 years of age – 90967
- 2-11 years of age – 90968
- 12-19 years of age – 90969
- 20 years of age or older – 90970
For example, a 15-year-old outpatient receives one day of ESRD-related services for dialysis without a complete evaluation. There are no other encounters in the 30-day period. This service would be reported as 90969 End-stage renal disease (ESRD) related service for dialysis less than a full month of service, per day; for patients 12-19 years of age.
ESRD Services May Mix and Match
When circumstances warrant, you may combine ESRD-related service codes (e.g., if a home dialysis patient or outpatient dialysis patient is admitted for a time as an inpatient). In CPT® the American Medical Association (AMA) provides the following example: “Home ESRD-related services are initiated on July 1 for a 57-yr-old male. On July 11, he is admitted to the hospital as an inpatient and is discharged on July 27 … 90970 is reported for each day outside of inpatient hospitalization (30 days/month less 17 days/hospitalization = 13 days).” Hemodialysis procedures rendered during the hospitalization (July 11-27) are reported as appropriate using 90935-90937.
Medicare Facility Billing Relies on Composite Payments
Facility charges for ESRD-related services provided to Medicare beneficiaries are paid based on a prospective payment system known as the basic case-mix adjusted composite payment system, which covers the costs of dialysis treatment and certain routine drugs, laboratory tests, and supplies furnished at home or in a facility. Other items and services (e.g., injectable drugs such as erythropoietin (EPO), non-routine laboratory tests) are not included in the composite rate, and they are billed separately to Medicare. For more information, see the Centers for Medicare & Medicaid Services (CMS) website.
Michelle A. Green, MPS, RHIA, CPC, FAHIMA, is a State University of New York (SUNY) distinguished professor at Alfred State College, teaching coding and reimbursement courses since 1984. She is also a published author of Delmar Cengage Learning’s textbooks: 3-2-1 Code It!, Understanding Health Insurance, and Essentials of Health Information Management.