All nephrology coders!!

lggrigg

Contributor
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Location
Oxnard
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General question....How would you code this note by just the assessment???
HPI: post transplant, course largely uneventful

Assessment:

Renal transplant n18.6
Hypertension I10
Anemia in chronic kidney disease n18.9
CKD-Mineral and bone disease n25.0
Hypercholesterolemia E78.0
Proteinuria r80.9
Post transplant Prophylaxis V65.40

Just needing a bit of reassurance on this one.

Thanks!
 

AmandaBriggs

Expert
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265
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Coeur d'Alene, Idaho
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This just looks like a list of diagnoses to me with no information as to their status or plan of care for each. I wouldn't code if all you have is a diagnosis list with no associated treatment plan.
 

Jennifer Turner

Networker
Local Chapter Officer
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41
Location
Indianapolis, IN
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Hi lggrigg,

Are you asking for clarification on the correct sequencing for the diagnosis (assessment)? If so, the first thing you need to do is code the etiology for the renal failure. For renal transplant the ICD code is not N18.6.... Also N18.9 & N18.6 will not be coded together. A very critical one is that when coding CKD you WILL NOT use the I10 for HTN. The more appropriate code will be from the I12 category, depending on the stage of CKD. If you need it broken down further, I'd be happy to help you. You can PM me.

Thanks!
 

gr8gal61

Guru
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Location
Corinth, TX
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If pt is dialysis dependent, pt is a N18.6 therefore the hypertension is I12.0, Anemia is D63.1 and not N18.9. It should be coded as:
I12.0
D63.1
N18.6
Z99.2
and the remaining DX codes. If the patient has long term use of insulin, you must use Z79.4 after the dependence on the dialysis.

Hope this helps.


General question....How would you code this note by just the assessment???
HPI: post transplant, course largely uneventful

Assessment:

Renal transplant n18.6
Hypertension I10
Anemia in chronic kidney disease n18.9
CKD-Mineral and bone disease n25.0
Hypercholesterolemia E78.0
Proteinuria r80.9
Post transplant Prophylaxis V65.40

Just needing a bit of reassurance on this one.

Thanks!
 
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