Wiki Specific stage of CKD documentation?

[clarks20]

What documentation is required to code a specific stage of chronic kidney disease? Here are three scenarios, how should they be coded?

E.g. – the provider stated in their assessment, “chronic kidney disease stage III – most recent GFR 31.”

E.g. – the provider stated in their assessment, “chronic kidney disease stable since 2019”. Elsewhere in the note, he pulled in lab results that show GFR 50 but did not include that in the assessment section.

E.g. – the provider stated, “chronic kidney disease stage II. Most recent GFR 45.” Note that the GFR does not correspond to the stage listed by the provider.

 

[thomas7331]

You can only code the diagnosis that is stated by the provider (N18.30, N18.9 and N18.2 in each of your examples) - it is considered incorrect coding to assign codes based on lab results or other information that is not supported by a physician's diagnostic statement. If the clinical indicators suggest that a more accurate or more specific diagnosis might be warranted, then it is appropriate to query the provider for clarification and/or an addendum.

 

[clarks20]

You can only code the diagnosis that is stated by the provider (N18.30, N18.9 and N18.2 in each of your examples) - it is considered incorrect coding to assign codes based on lab results or other information that is not supported by a physician's diagnostic statement. If the clinical indicators suggest that a more accurate or more specific diagnosis might be warranted, then it is appropriate to query the provider for clarification and/or an addendum.

Thank you Thomas. This is what we have been doing.