Coding Tip of the Month – February 2017

Hypertension, Diabetes and CKD

1. HTN & CKD

Many of us have been perplexed and confused by recent Coding Clinic advice in regard to Hypertension and CKD. While we may not always agree with published advice the official coding guidelines and coding clinic guidance are the rules that we must follow when reporting ICD-10-CM/PCS codes. This tip will hopefully clarify the intent of the guidelines and coding clinic advice so that coders are applying the rules and guidelines consistently to ensure data integrity, especially in absence of client specific guideliens. So let’s review:

The 2016 guidelines introduced an updated guideline I.A.15


The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related.

The 2016 guidelines also updated I.C.9.a.2

Hypertensive Kidney Disease

Assign codes from category I12, Hypertensive chronic kidney disease, when both hypertension and a condition classifiable to category N18, Chronic kidney disease (CKD), are present. CKD should not be coded as hypertensive if the physician has specifically documented a different cause.

The guidelines state we can “assume” conditions are related when the two conditions are linked by the term “with” unless the documentation states the conditions are unrelated. Many coders feel that unless documentation specifically states that CKD is not due to HTN we should continue to assume that CKD & HTN are related. Recent Coding Clinic advice has indicated that this is incorrect – all that is required is for the MD to document the CKD is due to a condition other than HTN to negate the assumed relationship between CKD & HTN. This is supported by two recent Coding Clinics:

Third Q 2016, p. 22

ESRD due to Polycystic Kidney Disease:

Patient is admitted with syncope. Final diagnosis states ESRD due to congenital polycystic kidney disease. The provider also noted polycystic kidney disease as underlying cause of hypertension. How should ESRD due to congenital polycystic kidney disease be coded?

N18.6 – ESRD

Q61.3 – Polycystic Kidney, unspecified

I15.1 – hypertension secondary to other renal disorders

Rationale: The official guidelines presume a cause-and-effect relationship and classify hypertension with CKD as hypertensive chronic kidney disease. However, in this case, the patient has ESRD due to a congenital disorder. The guidelines I.C.9.a.2 states CKD should not be coded as hypertensive if the physician has specifically documented a different cause.

AHA Question Response 1/4/17

This letter is in response to your request for assistance in coding hypertension with diabetic chronic kidney disease (CKD).

When the provider documents CKD due to diabetes, the provider has specified the cause of the CKD. As stated in the Official Coding Guidelines, I.C.9.a.2, CKD should not be coded as hypertensive if the physician has specifically documented a specific cause.

2. DM & CKD

Based on the updated guideline I.A.15 above we can also assume a link between CKD & DM unless the physician documents the CKD is due to another condition. This concept has also been clarified in Coding Clinic.

Second Q 2016, p. 36

The subterm “with” should be interpreted as a link between diabetes and any of those conditions under the term with – the physician does not need to document a link between the diagnosis of diabetes and chronic kidney disease to assign code E11.22. The link is assumed since the CKD is listed under the subterm “with” unless the provider documents CKD is unrelated to DM and due to some other underlying cause.

3. HTN, DM & CKD

When the documentation does not link the CKD to another condition and the patient has both DM & HTN, the CKD should be linked to both conditions. Again in accordance with guideline I.A.15 the coder can “assume” that both conditions are linked to the CKD unless the provider has linked to CKD to some other underlying cause.

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