Coding Tip of the Month – October 2019

CKD, Hypertension and Diabetes Mellitus:

The Third Quarter 2019 Coding Clinic provided additional explanation and interpretation  in regard to assuming a cause and affect effect relationship between CKD,  hypertension and diabetes mellitus. Although previous advice regarding CKD, hypertension and diabetes provided in Fourth Quarter 2018  was not mentioned in the Third Quarter 2019 advice comparing the two is essential to better understanding of how to code and report accounts with CKD, hypertension and diabetes mellitus. The table below compares the two.

4th Quarter 2018 (p. 88) 3rd Quarter 2019 (p. 3)
Question: Since ICD-10-CM presumes a relationship between both chronic kidney disease (CKD) and hypertension as well as diabetes mellitus and CKD, what are the appropriate code assignments when the provider documents type 2 diabetic mellitus with chronic kidney disease and the patient also has a diagnosis of hypertension?   Question: The patient presented for renal transplantation due to end stage renal disease (ESRD), and the provider’s final diagnostic statement listed, “ESRD due to diabetic nephropathy on dialysis, diabetic retinopathy, diabetic peripheral neuropathy, and hypertension.” The Official Guidelines for Coding and Reporting (I.C.9.a.2.) state, “CKD should not be coded as hypertensive if the provider indicates the CKD is not related to the hypertension.” In this case, since the provider documented ESRD due to diabetic nephropathy, would this statement be sufficient to indicate that the CKD is not related to hypertension?  
Codes: E11.22 Type 2 DM with diabetic chronic kidney disease I12.9 Hypertensive CKD with stage 1 through stage 4 CKD, or unspecified CKD N18.9 Chronic   Codes: E11.22 Type 2 DM with diabetic chronic kidney disease N18.6 ESRD I10 Hypertension

Documentation is Key:  The reason for the different advice provided is answered by very subtle differences in how the conditions were documented:

  • 3rd Q 2019:  the provider’s final diagnostic statement listed, “ESRD due to diabetic nephropathy on dialysis, diabetic retinopathy, diabetic peripheral neuropathy, and hypertension.” When the patient has diabetes, hypertension and chronic kidney disease (CKD) and the provider documents CKD due to diabetes or diabetic CKD, diabetic nephropathy or other similar terminology a causal relationship is indicated, and denotes the CKD is not related to the hypertension. In this case, assign a code for diabetic chronic kidney disease. Do not assign a code for hypertensive CKD, as the hypertension would be coded separately.
  • 4th Q 2018: the provider documents type 2 diabetic mellitus with chronic kidney disease and the patient also has a diagnosis of hypertension?  In this case the CKD is not documented as “due to” or secondary to either the DM or HTN. Therefore, the classification presumes a cause-and-effect relationship between both diabetes and CKD and hypertension and CKD. CKD is most likely related to both hypertension and diabetes when the patient has all three conditions. Both high blood sugar and high pressure in the blood vessels will cause the vessels to deteriorate, which can then damage the kidneys.

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