Question CKD coding with discepancy

thomas7331

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There is a guideline in ICD-10 that if the provider documents ESRD and a CKD stage, you would code only the ESRD, but I'm not aware of a guideline for multiple stages otherwise.

Your organization may have internal guidelines on this - for example, in hospital charts, the attending physician's diagnosis may take precedence over a consulting provider's diagnosis, or the diagnosis in the discharge summary may have priority over those in the daily notes.

In general, however, the auditors I've worked with would require a query to the provider in a situation such as this where the record contains conflicting or contradictory information and would likely cite an error if a code was assigned without obtaining clarification.
 
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