1. Jeff Kaufhold, MD FACP Nephrology Associates of Dayton Oct 2013
ICD 10 and Nephrology
Jeff Kaufhold, MD FACP
Nephrology Associates of Dayton
Oct 2013

2. Make the Diagnosis of Kidney Disease
Criteria
The ICD9 Code for CKD is 585.x where x = stage
The ICD 9 Code for ARF is 584.9
Decreased kidney function
eGFR of <60 ml/min/1.73 m2 for ≥ 3 months
Abnormal urinalysis including the presence of proteinuria or hematuria
Request a spot urine protein/creatinine ratio
(Normal is <30 mg/g)
Document an abnormal Renal Imaging Study
Based on the KDOQI guidelines there are specific findings to make the diagnosis of CKD and this information will be helpful in assessing the need for Timely Referral.

3. ICD 9 and 10 history ICD 9 developed by WHO
ICD 9 Clinical Modification developed for US in 1979.
CPT (clinical Procedural Terminology) codes used for ambulatory reporting.
ICD 10 developed in 1990’s
ICD 10 codes are now available in EPIC as of Oct
Mandatory use of ICD 10 is Oct 1, 2014.
CPT codes will continue to be used for physician practice settings/ office billing

4. ICD 10 after Oct 1 2014 Required for HIPAA transactions
ICD 10 CM (Diagnosis) codes Required for diagnosis of all services inpt or outpt
ICD 10 PCS (procedure) codes will be required on inpt claims
EPIC is starting the migration from ICD 9 to 10 codes now, and EPIC Premier inpt billing function includes the new ICD 10 coding structure.

5. ICD 10 Changes
Over 50% of new Dx are musculoskel, and 36 % are to distinguish R from L

6. ICD 10 Changes Up to 7 characters
Includes complication, severity, sequelae and other disease related parameters
Includes laterality
Includes initial or subsequent encounter code
Improved consistency of terminology
Combination codes are common i.e DM 2, controlled with renal manifestation
Has space holders for expansion

7. ICD 10 PCS coding for inptsD B 5 8 Z X
Section
Body system
Root operation
Body part
Approach
Device
qualifier
Med/Surg GI
Excision
Esophagus
Natural opening, endoscopic
No device implanted
Diagnostic
ICD 9 ; EGD with excisional biopsy,
ICD 10 0DB58ZX Endoscopic esophageal excision via natural or artificial opening

8. Most common issues in ICD 10
Laterality – as you code, EPIC will prompt you if right or left is required
Trimester specific
Many new orthopedic codes
Specificity is increased dramatically, so physician documentation must be more specific too.

9. Top 5 Clinical Documentation Issues
CHF
Sepsis
Renal Failure
Pneumonia
Respiratory Failure
Don’t use “Other” or accept a nonspecific diagnosis like DM, when a more specific term exists:
“DM 2 controlled with renal manifestation”

10. ICD 10 codes
Epic is migrating codes so over next year you may search using known ICD 9 codes
Can keep your PMHx and ongoing problem list NONSPECIFIC,
But your visit diagnosis list must be as specific, detailed, and include as many modifiers/ comorbidities/severity codes as possible

11. Common Diagnoses
ICD 9
DM 2 no mention of controlled or complication
DM 1 with renal manifestation
ICD 10
E11.65 DM 2 with hyperglycemia
E10.21 DM 1 with nephropathy AND
E10.65 DM1 with hyperglycemia

12. Top 5 Clinical Documentation issues
Condition
Common issues
Financial impact
CHF
Acute vs Chronic,
systolic vs diastolic
DRG 684 Renal failure without major complication or comorbidity
Sepsis
Sepsis, severe sepsis, SIRS, bacteremia
$ 3609
Renal Failure
Acute vs chronic
Stage with RIFLE criteria or CKD stage
With ATN is important
DRG 682 renal failure with major complication and comorbidity
Pneumonia
Cause / specific bacteria
Aspiration, simple vs complex, laterality
$ 9340
Respiratory Failure
Acute vs chronic, resp distress vs resp failure

13. Quality Performance hinges on Documentation
For inpts affects the hospital quality score
For our pts affects our practice score
Lack of clear documentation results in inappropriate assignment of complication codes for expected consequence of renal disease
Improved documentation results in lower reported complication rates,
higher complexity/ comorbidity scores reflect sicker population we care for.

14. Specific details for pts with ARF and CKD
DM Type I or II, controlled or uncontrolled
Use A1c over 6.5 as uncontrolled
With renal manifestation
Hypertension
With nephropathy
CKD stages 1-5, use ESRD for pts on dialysis in the medicare ESRD program.
AKI with ATN

15. Specific details for pts with ARF and CKD
AKI with ATN
Urine findings ATN casts
Oliguria
Creatinine over 2.5 or > 2X baseline
Were they pre-renal?
Does pt have TIN?
Complications of renal failure
Anemia of CKD
Secondary hyperparathyroidism of renal origin
Protein calorie malnutrition Severe = albumin less than 3.0

16. Estimated impact on physician practice
% increase in denials
Differences in authorization and referral triggers
Increased scrutiny of documentation
Impact on contracting/ preferred provider status based on severity of illness as reflected in coding.

17. ICD 10 and EPIC
ICD 10 diagnosis calculator goes live on Premier Epic Oct
Training modules available on Healthstream
Some codes require specific information, and a coding window will open to fill in R vs L, initial visit vs followup, sequelae.
Many codes won’t require more specificity, but for visits we should try to be as specific as possible.

18. ICD 10 and EPIC
Many codes won’t require more specificity, but for visits we should try to be as specific as possible.
We can double click item on the problem list like DM, HTN, Other disorder of renal etc, and make it more specific, without losing / deleting associations.

19. Diabetes codes
E DM due to underlying condition with diabetic nephropathy
E Drug or chemical induced DM with DM CKD
E DM I with Diab. Neph
E DM II with Diabetic Nephropathy
E13.22 Other specified DM with Diabetic CKD

20. CKD Codes N18.1 CKD stage 1 N18.2 CKD Stage 2 N18.3 CKD Stage 3
N18.6 ESRD
N18.9 CKD unspecified

21. CKD and DM codes Code the DM first, then the stage:
E10.22 Type I DM with nephropathy
N18.6 ESRD
Same for Hypertensive Kidney Disease
I12 hypertensive Kidney disease
N18.4 CKD Stage 4
If pt has heart and kidney disease, use
I13 hypertensive Heart and CKD
CHF uses I 50 codes

22. HTN and CKD Codes I12.0 Hypertensive CKD with Stage 5 or ESRD
I12.9 “” “” with stages 1-4 CKD
I Hypertensive Heart and CKD without heart failure, Stages 1-4
I Hypertensive Heart and CKD without heart failure, Stage 5 or ESRD
I13.2 Hypertensive Heart and CKD with heart failure, Stage 5 or ESRD

23. Nephrology Codes N 0 – 8 Glomerulonephritis
N 10 Interstitial Nephritis
N 17 ARF
N 18 CKD
N 20 Kidney stone
N Bladder disorders
N 40 BPH
ICD10Data.com

24. Nephrology Codes PCKD Q 61.3 Acquired cyst N 28.1
Q Congenital Malformations of the urinary System
R 80 Proteinuria
R 81 Glycosuria
R 60 Edema
ICD10data.com

25. Nephrology Codes for ICD 10
Electrolyte disorders: E 87
High K E 87.5
Protein Calorie Malnutrition
E 43 severe
E 44 Mild to Moderate
Secondary hyperparathyroidism of renal origin
N 25.81

26. Nephrology Common Codes
Anemia of CKD D 63.1
Lupus Nephritis
SLE M 32 – not completely mapped yet
Renal transplant – has not yet mapped
(as of Oct 2013)
Dysfunction would be coded with the ARF or CKD code to denote pts renal function at time of visit
N 17.9 ARF
N 18.3 CKD stage 3

27. Transplant Specifics
Just because your patient has a transplant, they still have Chronic Kidney disease.
List the transplant
List the CKD stage for chronic allograft dysfunction
List acute allograft dysfunction if present
List the cause of their underlying CKD/ESRD
List comorbidities and complications
Are they anemic due to Cellcept use?
Did they develop NODAT?
Doc talk, Precyse University, Oct 2013

28. PCKD specifics PCKD Q 61.3 Acquired cyst N 28.1
Q Congenital Malformations of the urinary System
Autosomal Dominant or recessive?
Liver /other cysts?