Office Visit 6/6/2022: 76-year-old female, lives with daughter and son-in-law, follow up on CKD
PMH: Overweight, Anemia, Anxiety, Hypertension, Malignancies of Uterus and Kidney, GE Reflux Disease
Home Medications:
- Verapamil (CALAN SR) 180mg ER tablet
- Vitamin D3,25 mcg tablet(1000unit), take 2,000 units by mouth
- Calcium carbonate 1,500mg (600mg calcium) tablet take 600mg of calcium by mouth daily with breakfast
Vitals: BP 147/84, HR 98, Temp 98.4, SpO2 97%, Weight 84.2 kg, Height 173.7 cm, BMI 27.91 kg/m²
Lab Values:
| Date | Creat, P | GFR |
| 4/13/22 | 1.57 ^ | 45 v |
| 3/2/22 | 1.68^ | 42 v |
| 1/19/22 | 1.52^ | 47 v |
| 12/08/21 | 1.56^ | 46 v |
| 10/27/21 | 1.56^ | 46 v |
| 6/23/21 | 1.68^ | 42 v |
| 4/12/21 | 1.56^ | 46 v |
History of Present Illness (HPI):
The patient has a history of kidney cancer, Urothelial carcinoma, in which she underwent right nephrectomy and cystectomy with ileal conduit in March 2019, since then she has elevated creatinine and chronic kidney disease in the setting of solitary kidney.
She recently admitted to the hospital after left ankle fracture, discharged to rehab short term, and now back at daughter’s home.
Currently on Verapamil, since last year has had some weight gain. 88 kg in October, down to 84.2 kg this visit, slightly elevated blood pressure, and creatinine is slightly elevated up to 1.70mg/dL. Her recent CT, fortunately, showed no evidence of metastasis in her abdomen and no evidence of recurrence.
BP readings from last 3 encounters: 4/13/22: 144/84, 10/27/21: 123/73, 4/12/21: 135/80
Assessment/Plan:
- CKD
- Solitary Kidney
- Renal Cancer
Patient has kidney cancer, underwent right nephrectomy in 2019, since then has elevated creatinine and CKD in setting of solitary kidney. CT showing focal scar in left kidney. Blood work planned every 3 months.
Patient has Oncology follow up appointment in 6 months, ongoing surveillance, Ostomy looks good.
4. Hypertension
We reviewed her blood work, blood pressure, urine testing, and CT report together. Discussed creatinine this visit is slightly elevated a from last visit, but still in range that she had before. No proteinuria. She has not been checking her blood pressure at home. Instructed to start checking blood pressure at home and keep us informed. Also, will start to be more active and lose some weight.
Follow-Up: Return in 3 months
Question: Are there query opportunities based on the scenario stated above?
Discussion: Provider visit diagnoses include Renal Cancer, CKD, Hypertension
UASI Recommends:
- Query stage of CKD
- Query for current status of Renal Cancer: Active versus personal history
Documentation With and Without Clarification:
| Documentation Without Clarification: | Documentation With Clarification: |
| Diagnoses: CKD Renal Cancer Solitary Kidney Hypertension Factor: Demographic base factor: Community Enrollee-Non-dual Benefit, aged (Female 75-79): 0.461 HCC 11 (Colorectal, Bladder and Other Cancers) risk factor: 0.307 | Diagnoses: CKD, Stage3a Ileal Conduit Solitary Kidney, Personal History of Renal Cancer Hypertension Factor: Demographic base factor: Community Enrollee- Non-dual Benefit, aged (Female 75-79): 0.461 HCC 138 (Chronic Kidney Disease, Moderate (Stage 3)) risk factor: 0.069 HCC 188 (Artificial Openings for Feeding or Elimination) risk factor: 0.534 |
| HCC Total: 0.768 | HCC Total: 1.064 |
CDI Educational Tips:
ICD 10 coding guidelines assume a cause and effect relationship between CKD and hypertension when a patient has both conditions, unless explicitly stated as not related. When present together, both conditions should be documented and coded.
Educate providers to classify CKD based on the cause and the GFR category. What is the stage of kidney disease? The higher the stage of kidney disease, the more care the patient is likely to need. When the stage is not documented, it is coded as unspecified, which is not associated with a risk factor score. CKD stages 3,4,5, and End stage renal disease (ESRD) contribute to CMS and HHS-HC risk adjustment.
Recent Office of Inspector General (OIG) audit findings included incorrectly submitted diagnoses codes for colon, renal, lung, and breast cancer where medical records indicated the individual patient had previously had cancer, but their records did not justify a cancer diagnosis at the time of the physician’s service. For example, documentation noted the cancer was surgically treated over two years prior with no evidence of disease currently.
‘History of’ can be a vague term and have different meanings. Educate providers to discuss condition(s) in current state and that diagnoses that have resolved or are no longer treated should not be reported.
Query the provider when the documentation is unclear or inconsistent. When working with Providers encourage them to update the patient problem list: resolving or revising to historical conditions.
Z codes are often overlooked by providers in the office setting. TOAD is an abbreviation that helps providers quickly remember:
Transplants, Ostomies, Amputations/AIDS, Dialysis Status
This is a short synopsis of a possible patient record and is not intended to be all inclusive. This is for educational purposes only and not intended to replace your institutional guidelines.