Sequence ESRD Diagnoses with Care

Patients with end stage renal disease (ESRD), and other stages of chronic kidney disease (CKD), often also suffer from conditions such as hypertension, diabetes mellitus, anemia, and transplant complications. Be sure to sequence these conditions properly when assigning ICD-9-CM codes, as follows:

Diabetes: Section I.C.3.a.4 of the ICD-9-CM Official Guidelines for Coding and Reporting 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 Type II diabetic with ESRD presents to his physician’s office for 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
  • 585.6 End stage renal disease (ESRD)

Anemia: Section I.C.4.a.1 of the ICD-9-CM Official Guidelines for Coding and Reporting 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 is sequenced first. For example, in a patient diagnosed with “anemia in end state renal disease,” if anemia is the reason for the encounter, report 285.21 Anemia in chronic kidney disease, followed by 585.6.

Hypertensive chronic kidney disease: Section I.C.7.a.3 of the ICD-9-CM Official Guidelines for Coding and Reporting 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). Whichever condition is the reason for the encounter is sequenced first.

Kidney transplant complications: Section I.C.17.f.2.b of the ICD-9-CM Official Guidelines for Coding and Reporting 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 kidney transplant may continue to have CKD because the kidneys are not restored to full function. Do not assume that a patient who has had a kidney transplant and chronic kidney disease 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 Official Guidelines for Coding and Reporting (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.”

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 406 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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