ICD-10: Coding Snapshot
HISTORY OF PRESENT ILLNESS: This is a follow up for this 69-year-old gentleman with stage IV chronic kidney disease. His creatinine has ranged between 4 and 4.5 over the past six months (since I have been following him). I have been trying to get him educated about end-stage kidney disease and we have been unsuccessful in getting him into classes. On his last visit, I really stressed the importance of him taking his medications adequately and not missing some of the doses, and he returns today with much better blood pressure control. He has also bought a machine at home, and states his blood pressure readings have been better. He has not gone to the transplant orientation class yet and has not been to dialysis education yet, and both of these I have discussed with him in the past.
REVIEW OF SYSTEMS: Really negative. He continues to feel well. He denies any problems with shortness of breath, chest pain, swelling in his legs, nausea or vomiting, and his appetite remains good.
VITAL SIGNS: On exam, his blood pressure is 140/57, pulse 58, current weight is 67.1 kg. Again, his blood pressure is markedly improved over his previous readings. GENERAL: He is a thin gentleman in no distress. LUNGS: Clear. CARDIOVASCULAR: Regular rate and rhythm. Normal S1 and S2. I did not appreciate a murmur. ABDOMEN: Soft. He has a very soft systolic murmur at the left lower sternal border. No rubs or gallops. EXTREMITIES: No significant edema.
LABORATORY DATA: Today indicates that his creatinine is 4.5 and stable, ionized calcium 8.5, intact PTH 458, and hemoglobin stable at 10.9. He is not on EPO yet. His UA has been negative.
1. Chronic kidney disease, stage IV. His estimated GFR is 16 mL per minute. He has no uremic symptoms.
2. Hypertension, which is finally better controlled.
RECOMMENDATION: He needs a number of things done in terms of follow up and education. I gave him more information again about dialysis education and transplant, and instructed him he needs to go to these classes. I also gave him websites that he can get on to find out more information. I have not made any changes in his medications. He is getting blood work done prior to his next visit with me.
I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
N18.4 Chronic kidney disease, stage 4 (severe)
Rationale: The patient presents for a follow up of his stage four chronic kidney disease and hypertension. According to the guidelines (I.C.9.a.2) a code form category I12 is assigned when both hypertension and chronic kidney disease are present. ICD-10-CM presumes a cause-and-effect relationship between hypertension and chronic kidney disease and classifies chronic kidney disease with hypertension as hypertensive chronic kidney disease. Although dialysis is mentioned, the patient is not on dialysis, so there is no additional coding necessary, at this time.
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