Wiki N18.6 ESRD "without" Z99.2?

[ChattRiskCoder]

Hi there,

If a provider only documents the below, would we need to add the Z99.2 as well due to the "use additional" note in the tablular? My thoughts are no because the provider did not specifically state that the patient is on dialysis. Thoughts?

1. CKD 4 due to diabetes 2. ESRD

Any advice is appreciated!

 

[michellepilcher]

The patient has either CKD4 or ESRD. CKD4 does not require dialysis and ESRD does. You will need to clarify with the provider the true diagnosis.

 

[ChattRiskCoder]

Per guidelines though, if ESRD is documented on an encounter with a lower stage, ESRD would be captured.

My question is can Z99.2 be automatically added to an encounter when the provider documents ESRD? Thanks so much for your reply!

 

[michellepilcher]

I would not add it unless it's documented the patient is on dialysis. Not everyone opts for dialysis when it is time, and many opt to 'deselect' from dialysis treatment after starting it.

 

[margiemed117]

Hi there,

If a provider only documents the below, would we need to add the Z99.2 as well due to the "use additional" note in the tablular? My thoughts are no because the provider did not specifically state that the patient is on dialysis. Thoughts?

1. CKD 4 due to diabetes 2. ESRD

Any advice is appreciated!

I agree, unless you query the provider I don't believe you should add the dialysis code.