Question CKD likely due to HTN

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Dear all,
Physician has documented under outpatient record’s assessment as, “CKD likely due to HTN”. I am doubtful as whether to code this HTN as I12.9 or I10. I know that there is a presumptive causal linkage between CKD and HTN, however, here physician is not sure if the CKD is related to HTN or not. This is a case of uncertain linkage and we don’t code uncertain diagnosis in Outpatient setting. Please suggest what should be the correct coding for this scenario. Thanks.
 

twizzle

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There is no link here because 'likely' is indicating uncertainty and is not confirmed (yet). Follow the coding guidelines and code as I10, not I12.9 until that link is established for certain.
 

thomas7331

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I12.9 would be correct. The ICD-10 guidelines state: These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. In your example, the documentation does not state that these are unrelated. In fact, it states that they are likely related.
 

twizzle

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I12.9 would be correct. The ICD-10 guidelines state: These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. In your example, the documentation does not state that these are unrelated. In fact, it states that they are likely related.
I would have to disagree. What if it transpired later that the CKD was totally remote from HTN? I would willingly code I12.9 if the provider said CKD and HTN but 'likely is casting some element of doubt so I'd still go with I10.
 

chantal777

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Dear all,
Physician has documented under outpatient record’s assessment as, “CKD likely due to HTN”. I am doubtful as whether to code this HTN as I12.9 or I10. I know that there is a presumptive causal linkage between CKD and HTN, however, here physician is not sure if the CKD is related to HTN or not. This is a case of uncertain linkage and we don’t code uncertain diagnosis in Outpatient setting. Please suggest what should be the correct coding for this scenario. Thanks.
I agree with you because the provider documentation states "likely due to HTN" I would rather query for clarification after all it's an outpatient setting. Explain to provider likely, maybe, cannot be coded in outpatient setting.
hope that helps
 
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Yes, the doubt arised because some of the colleagues argued that the word “Likely” here holds no value as ckd comes under HTN under the sub term “with” which means “associated with” or “due to”. In this case the classification presumes a causal linkage between CKD and HTN and it can be coded as I12.9.
 

csperoni

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I would have to disagree. What if it transpired later that the CKD was totally remote from HTN? I would willingly code I12.9 if the provider said CKD and HTN but 'likely is casting some element of doubt so I'd still go with I10.
I'm with Thomas on this due to the guideline. The documentation does not "clearly state the conditions are unrelated." Even with some element of doubt, it is not clearly stated they are unrelated.
 

thomas7331

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I would have to disagree. What if it transpired later that the CKD was totally remote from HTN? I would willingly code I12.9 if the provider said CKD and HTN but 'likely is casting some element of doubt so I'd still go with I10.
In this situation, I12.9 is the default coding when there is an element of doubt. I10 requires certainty that the conditions are unrelated. A diagnosis can change after the fact - it happens all the time. It wouldn't change how it is to be coded at the current encounter.
 
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I have got one response over the internet which says "Cause of CKD described with terms of uncertainty: In accordance with ICD-10-CM Official Guidelines for Coding and Reporting, when the cause of CKD is documented with terms of uncertainty, do not code the cause as if it is confirmed. Example: Chronic kidney disease stage 4 “likely” due to diabetes – do not code diabetic CKD because the documentation indicates it is not certain that diabetes is the cause".

This is similar to our scenario. When this says not to code Diabetic CKD, if we agree to this, even Hypertensive CKD should not be considered.
To check the document, you can paste the below given link to your browser and see.

Reference - https://docushare-web.apps.cf.humana.com/Marketing/docushare-app?file=2660567
 
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I'm not sure how people are not aware of this till now. Even I am the one who was not aware that there is an AHA coding clinic, released on 1st quarter of 2021, which says as below -
Question:
In the outpatient setting, the provider documented gastrointestinal (GI) bleeding likely due to gastric ulcer and diverticulosis. Although the provider confirmed the gastric ulcer and diverticulosis, the GI bleeding is documented as “likely”, which is an uncertain diagnosis, not coded in the outpatient setting. This is a conundrum for coding professionals since the “With” guideline (I.A.15) would link these conditions. Should the “With” guideline be applied when the linked diagnosis is uncertain (i.e., possible, probable, likely, suspected, etc.)?
Answer:
In the outpatient setting, assign codes K92.2, Gastrointestinal hemorrhage, unspecified, K57.90, Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding, and K25.9, Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation for a GI bleeding likely due to gastric ulcer and diverticulosis. While the ulcer and diverticulosis are confirmed diagnoses (highest degree of certainty), the source of the bleed is not certain. When the linkage between two diagnoses is documented in terms indicating uncertainty, the Uncertain Diagnosis guideline applies, and a combination code indicating a presumed linkage should not be assigned.

The Official Guidelines for Coding and Reporting, Section IV.H, states: Do not code diagnoses documented as “probable,” “suspected,” “questionable,” “rule out,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit.
 

thomas7331

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I'm not sure how people are not aware of this till now. Even I am the one who was not aware that there is an AHA coding clinic, released on 1st quarter of 2021, which says as below -
Question:
In the outpatient setting, the provider documented gastrointestinal (GI) bleeding likely due to gastric ulcer and diverticulosis. Although the provider confirmed the gastric ulcer and diverticulosis, the GI bleeding is documented as “likely”, which is an uncertain diagnosis, not coded in the outpatient setting. This is a conundrum for coding professionals since the “With” guideline (I.A.15) would link these conditions. Should the “With” guideline be applied when the linked diagnosis is uncertain (i.e., possible, probable, likely, suspected, etc.)?
Answer:
In the outpatient setting, assign codes K92.2, Gastrointestinal hemorrhage, unspecified, K57.90, Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding, and K25.9, Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation for a GI bleeding likely due to gastric ulcer and diverticulosis. While the ulcer and diverticulosis are confirmed diagnoses (highest degree of certainty), the source of the bleed is not certain. When the linkage between two diagnoses is documented in terms indicating uncertainty, the Uncertain Diagnosis guideline applies, and a combination code indicating a presumed linkage should not be assigned.

The Official Guidelines for Coding and Reporting, Section IV.H, states: Do not code diagnoses documented as “probable,” “suspected,” “questionable,” “rule out,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit.
Thank you for sharing this. Unfortunately, I think that sometimes Coding Clinic sometimes makes things more confusing rather than less when they publish responses like this. This would suggest that they are giving guidance to not code hypertension as related to CKD when documented as 'likely related', which directly contradicts the official guidelines that I quoted above that instructs to code the hypertension as related 'unless the documentation clearly states the conditions are unrelated'.

In the larger coding and audit organizations that I've had contact with, in cases where there is a contradiction between ICD-10 and Coding Clinic, the ICD-10 Official Guidelines take precedence and carry more weight. So I would stick with my original opinion. However, if you coded I10 and received an error in an audit, you could certain cite this article as support for your code choice.
 
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thomas7331

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I agree with you because the provider documentation states "likely due to HTN" I would rather query for clarification after all it's an outpatient setting. Explain to provider likely, maybe, cannot be coded in outpatient setting.
hope that helps
I would not query for clarification in this situation - the provider's opinion is perfectly clear. They would not say that it's 'likely related' if they had enough information to say that for certain. And it's not true that it cannot be coded - it can be coded, and it's just up to the coder to determine the most appropriate code. There's no need to involve the provider in this.

 

csperoni

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After reading the additional posts, I think I understand better why there are differing opinions here.
I was reading the original question as the patient definitely has CKD, and the patient definitely has HTN. The question was whether or not they are related. The original post asked which HTN code to use, not whether or not HTN should be coded. My opinion remains to code as related since it is not documented as clearly unrelated, assuming the HTN
I think others are reading the original question as the patient definitely has CKD, and the patient LIKELY has HTN. If so, then I would not code the HTN at all, and only the CKD.
 
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