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Wiki CKD coding with discepancy

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birdldy12001@yahoo.com

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Is there any documentation that will tell you how to code CKD if multiple stages are listed in the chart?
 
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.
 
I am having a similar problem as well. I have a provider that sometimes documents two stages of CKD. I do send a query back to have her clarify but don't always get it. As coders we aren't able to code based on lab results, so how should a situation like this be handled? I don't see a guideline in the book stating you can't code both, however, there can only really be one stage on that particular visit. I have attached an example, however it cut off a little bit. It actually states- CKD 3B-4 and then the GFR results.
 

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warrenfamily103@gmail.com said:
I am having a similar problem as well. I have a provider that sometimes documents two stages of CKD. I do send a query back to have her clarify but don't always get it. As coders we aren't able to code based on lab results, so how should a situation like this be handled? I don't see a guideline in the book stating you can't code both, however, there can only really be one stage on that particular visit. I have attached an example, however it cut off a little bit. It actually states- CKD 3B-4 and then the GFR results.
Click to expand...
I think if multiple stages were documented by the same provider at the same encounter and no query was possible, I would code N18.9 for an unspecified stage. 'Unspecified', by my understanding, means just that - that the specific stage is not stated or is not clear from the record.
 
Thank you for the feedback. I did query the provider and have attached their response. We are still on paper charts so it's just handwritten. Hopefully moving towards EMR soon :)
I appreciate any feedback on how to handle this particular situation. I hate to keep coding unspecified, but I am unsure how to explain this to the provider any better than I already have.
 

Attachments

warrenfamily103@gmail.com said:
Thank you for the feedback. I did query the provider and have attached their response. We are still on paper charts so it's just handwritten. Hopefully moving towards EMR soon :)
I appreciate any feedback on how to handle this particular situation. I hate to keep coding unspecified, but I am unsure how to explain this to the provider any better than I already have.
Click to expand...
Wow. I took a look at your provided attachment and that's not just his/her note to keep up with the patient. The insurance company would be able to see it, too, if they requested the record. S/he has to consider that s/he isn't the only one who will see it, no matter what s/he says. Anyone else would be confused by both stages being listed in the record for that specific encounter.
 
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