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Wiki Coding the GFR

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pkb1969

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As a coding rule, coders cannot code the stage of Chronic Kidney Disease unless it is documented in the note. I have a dilemna. The GFR is documented in the note as 31, but the Dr. used the common Chronic Kidney Disease Code for the diagnosis instead of a more specific code to show the stage. Am I allowed to change this code since it states in the note as the GFR to be 31??
 
No in this case the stage must be documented. You can request the provider addend the note before you submit the claim so that it can be coded . However coders are not to interpret results for a diagnosis.
 
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