Question What diagnosis can be coded if the progress note supports Chronic Kidney Disease stage 4 and CKD stage 5, no evidence of dialysis ?

[vardharajantc]

What diagnosis can be coded if the progress note supports Chronic Kidney Disease stage 4 and CKD stage 5, no evidence of dialysis

 

[thomas7331]

When the medical record is contradictory as in a case like this, ICD-10 guidelines state to query the physician for clarification.

 

[sls314]

I agree with Thomas.

Also wanted to add that if you're working in risk adjustment and can't query the physician, your project should have rules for how they want you to handle that circumstance. I'd refer to your project guidelines or ask your manager.

 

[vardharajantc]

When the medical record is contradictory as in a case like this, ICD-10 guidelines state to query the physician for clarification.

Thank you

 

[vardharajantc]

I agree with Thomas.

Also wanted to add that if you're working in risk adjustment and can't query the physician, your project should have rules for how they want you to handle that circumstance. I'd refer to your project guidelines or ask your manager.

Thank you