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Clinical Documentation Impacts with ICD-10

ICD-10 requires physicians to code with a much higher level of specificity. This resource covers ICD-10 codes for specific conditions and requirements including renal failure, causative codes, diabetes, glomerular disease, hypertensive chronic kidney disease, anemia, adverse effects, poisonings or toxic effects, complications of care and body mass index.


Clinical Documentation Impacts with ICD-10

As of October 1, 2016 Greater Specificity is REQUIRED!

Medicare and many private payers are going to decrease the ability to submit less specified codes without penalty

In order to bill a more specific diagnosis you need to start documenting more detail. ICD-10 codes require that you document:

Onset of Care
Anatomical Site Specificity
Laterality
Disease Severity
Etiology & Manifestation
Complications
Combination Codes
Non-Specific/Unspecified
Conditions that may add complexity to treatment


REMEMBER:

9 Avoid "over-coding" - if it isn’t relative to the visit, don’t code it
Additional codes should be reported where required by coding conventions


• code also
• use additional code

2 or more codes may be required to fully describe a condition

Documenting Renal Failure

Identify if renal failure is acute or chronic renal failure

Acute Renal Failure with:
• Tubular necrosis
• Acute cortical necrosis
• Medullary necrosis
• Other acute kidney failure

Stage of Chronic Kidney Disease: Stage 1-5

End-Stage Renal Disease
• Compliant with dialysis
• Non-compliant with dialysis

Identify any associated diabetic or hypertensive chronic kidney disease


Kidney Failure


Code also associated underlying condition
N17.0 – AKF with tubular necrosis
N17.1 – AKF with acute cortical necrosis
N17.2 – AKF with medullary necrosis
N17.8 – Other acute kidney failure
N17.9 – Acute kidney failure, unspecified

Other Renal
Q61.2 – Polycystic kidney adult type
Q61.5 – Medullary cystic kidney
R34 – Anuria & oliguria
R31.0 – Hematuria, gross
R31.9 – Hematuria, unspecified

N18.1 – Chronic Kidney Disease, Stage 1
N18.2 – Chronic Kidney Disease, Stage 2
N18.3 – Chronic Kidney Disease, Stage 3
N18.4 – Chronic Kidney Disease, Stage 4
N18.5 – Chronic Kidney Disease, Stage 5
N18.6 - End Stage Renal Disease requiring dialysis

Use additional code to identify dialysis status (Z99.2)
Z91.15 – Noncompliance with renal dialysis

Code first any associated:
•Diabetic CKD (E08.22, E09.22, E10.22, E11.22, E13.22)
•Hypertensive CKD (I12.X, I13.X)

Use additional code to identify kidney transplant status, if applicable (Z94.0)

Requirements for Causative Codes

As of Date of Service October 1, 2016



Causative codes must be documented when using N17.0 – N17.9 "Kidney Failure" or N18.1-N18.5 "CKD" or N18.6 "ESRD"
(For all place of services)

Causative Codes are usually the following:
Diabetes
Glomerular Disease
Hypertension

If the causative reason cannot definitively be determined, it would be appropriate to use:
N19 Unspecified Renal Failure
N17.9 Acute Kidney Failure, Unspecified
N26.1 Atrophy of Kidney – Terminal

Symptom codes such as the following could be used depending upon what is known from the office visit or referral data.
R31.9 Hematuria
R80.9 Proteinuria

Documenting Diabetes

Document the type, any complications or manifestations and the current treatment
Identify when diabetes is accompanied by hyperglycemia or hypoglycemia
State if hypoglycemia results in coma

If there are complications/manifestations of the diabetes, additional details may be necessary for the following conditions:
• Arthropatphy
• Site of Ulcer
• Severity of retinopathy
• With or without macular edema
• Stage of CKD
• Gangrene
• Hyperglycemia


Diabetes Mellitus
Use additional code to identify any insulin use (Z79.4)


Type I

E10.21 – Type I DM with Diabetic Nephropathy
E10.22 – Type l DM with Diabetic CKD
Use additional code to identify stage of CKD (N18.1 – N18.6)
E10.29 – Type I DM with other Diabetic Kidney Complications such as DM with Renal Tubular Degeneration

Type II

E11.21 – Type II DM with Diabetic Nephropathy
E11.22 - Type Il DM with Diabetic CKD
Use additional code to identify stage of CKD (N18.1 –N18.6)
E11.29 – Type II DM with other Diabetic Kidney Complications such as DM with Renal Tubular Degeneration

 


E08.21 – DM due to underlying condition with Diabetic Nephropathy
E08.22 – DM due to underlying condition with Diabetic Chronic Kidney Disease
Code first the underlying condition such as malignant neoplasm (C00 – C96)
Use additional code for stage of CKD (N18.1-N18.6) Use additional code for any insulin use (Z79.4)
E16.2 – Hypoglycemia unspecified

Documenting Glomerular Disease


Glomerular Disease
Code also any associated kidney failure N17-N19


Third Digit

N00 – Acute nephritic syndrome
N01 – Rapidly progressive nephritic syndrome
N02 – Recurrent and persistent hematuria
N03 – Chronic nephritic syndrome
N04 – Nephrotic syndrome
N05 – Unspecified nephritic syndrome
N06 – Isolated proteinuria with specified morphologic lesion
N07 – Hereditary nephropathy NEC

Fourth Digit N00-N07

.0 with minor glomerular abnormality
.1 with focal and segmental glomerular lesions
.2 with diffuse membranous GN
.3 with diffuse mesangial proliferative GN
.4 with diffuse endocapillary proliferative GN
.5 with diffuse mesangiocapillary GN
.6 with dense deposit disease
.7 with diffuse crescentic GN
.8 with other morphologic changes
.9 with unspecified morphologic changes

 


M32.14 SLE GN • M32.15 SLE tubular-interstitial • D59.3 HUS
M31.0 Goodpasture Syndrome • M31.31 Wegeners



Glomerular Disorders in Diseases Classified Elsewhere


N08 Glomerular disorders in diseases classified elsewhere

Glomerulonephritis
Nephritis
Nephropathy

Code First: underlying disease, such as:
• amyloidosis (E85.-)
• congenital syphilis (A50.5)
• cryoglobulinemia (D89.1)
• disseminated intravascular coagulation (D65)
• gout (M1A.-, M10.-)
• microscopic polyangiitis (M31.7)
• multiple myeloma (C90.0-)
• sepsis (A40.0-A41.9)
• sickle-cell disease (D57.0-D57.8)

N08 is a manifestation code and cannot be the primary diagnosis



Excludes: glomerulonephritis, nephritis and nephropathy (in):
• antiglomerular basement membrane disease (M31.0)
• diabetes (E08-E13 with .21)
• gonococcal (A54.21)
• Goodpasture’s syndrome (M31.0)
• hemolytic-uremic syndrome (D59.3)
• lupus (M32.14)
• mumps (B26.83)
• syphilis (A52.75)
• systemic lupus erythematosus (M32.14)
• Wegener’s granulomatosis (M31.31)
• pyelonephritis in diseases classified elsewhere (N16)

 


Documenting Hypertensive Chronic Kidney Disease

If hypertension and chronic kidney disease are present, report as hypertensive chronic kidney disease


Hypertensive Chronic Kidney Disease


I10 Essential (primary) Hypertension

I12 Hypertensive chronic kidney disease
I12 is a code family requiring a 4th digit
Excludes 1: hypertension due to kidney disease (I15.0, I15.1)
• Renovascular hypertension (I15.0)
• Secondary hypertension (I15.-)
Excludes 2: acute kidney failure (N17.-)
Includes: any condition in N18 and N26 - due to hypertension
• Arteriosclerosis of kidney
• Arteriosclerotic nephritis (chronic)(interstitial)
• Hypertensive nephropathy
• Nephrosclerosis
I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease
Use additional code to identify the stage of chronic kidney disease (N18.5, N18.6)
I12.9 Hypertensive chronic kidney disease stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
• Hypertensive chronic kidney disease NOS
• Hypertensive renal disease NOS
Use additional code to identify the stage of chronic kidney disease (N18.1 – N18.4, N18.9)
I13 – Hypertensive heart and chronic kidney disease I13 is a code family requiring a 4th digit
Includes: any condition in I11. – With any condition in I12. –
• Cardiorenal disease
• Cardiovascular renal disease
I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through 4 chronic kidney disease, or unspecified chronic kidney disease
Use additional code to identify type of heart failure (I50.-)
Use additional code to identify stage of chronic kidney disease (N18.1 – N18.4, N18.9)
I13.10 Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic
• Hypertensive heart disease and hypertensive chronic kidney disease NOS
Use additional code to identify the stage of chronic kidney disease (N18.1 – N18.4, N18.9)
I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease
Use additional code to identify the stage of chronic kidney disease (N18.5, N18.6)
I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease
Use additional code to identify type of heart failure (I50.-)
Use additional code to identify the stage of chronic kidney disease (N18.5, N18.6)

Documenting Anemia

If Nutritional Anemia:
What is the deficiency due to?
Vitamin(s)
Minerals
You need to document the following for Anemia:
Type of Anemia:
• Nutritional
• Hemolytic
• Aplastic
• Result of Blood Loss
• Acute or Chronic
Link Laboratory Findings to a related diagnosis
Cause OR provide a statement indicating the "unknown cause"
List the name & purpose of medications or other substance causing anemia

Anemia


D50.0 - Chronic Blood Loss Anemia
D50.9 - Iron Deficiency Anemia
D61.9 - Aplastic Anemia
D62 - Acute blood loss Anemia
D63.1 - Anemia in chronic kidney disease
Can’t be primary – Code first CKD (N18.-)

Documenting Adverse Effects, Poisonings, or Toxic Effects

Document the substance causing the complications or manifestations

• Indicate abuse or dependence with the substance
Identify complications or manifestations caused by a substance:
• Cardiac arrest
• Convulsions
• Anaphylactic reaction
Specify any external causes
Provide information regarding the circumstances surrounding the event, or mindset of the patient to help identify if the event was accidental, intentional or the result of an assault

 

Documenting Complications of Care

Complications of care are based solely on the provider's documentation of the relationship between the condition and the care or procedure
Must be stated by the provider that the condition is a complication – Can't be assumed

Documenting Body Mass Index

*Should only be used as a 2nd diagnosis

Reporting obesity now includes causation as due to:
Excess calories
Hypoventilation
Drug induced (make sure you also note what drug)
Need to use additional code (Z68-) to identify the BMI



Important Note: BMI must be diagnosed by the provider, and cannot be calculated by the coder or other office staff. If it is not diagnosed the staff can query the physician to clarify if the provider would like to addendum note with BMI diagnosis.



At NPS, we are committed to providing resources and solutions that deliver economic growth, practice stability and operational efficiencies to our physician partners. NPS offers coding review services to help guide your practice in accurate coding. Click here to learn more about our coding review or feel free to email or call us to speak directly to a member of the NPS team.

This guide is provided for informational purposes only, not as advice for your specific practice, and it should not be solely relied upon for appropriate coding.