Patients who have had kidney transplants may still have some form of Chronic Kidney Disease because the kidney transplant may not fully restore kidney function. Code Z94.0 Kidney Transplant Status may be assigned with a Chronic Kidney Disease code. “It is incorrect to assume that mild or moderate CKD following a transplant is a transplant failure unless it is documented as such in the medical record.”1
If there is documentation that a patient who has severe CKD or ESRD with a kidney transplant is having transplant failure, rejection, or some other transplant complication, Code T86.1 Complications of Kidney Transplant is assigned. If the documentation is unclear whether there is transplant failure or rejection, it is necessary to query the provider because the CKD or ESRD alone is not a transplant complication.
Per Coding Clinic Second Quarter 2019, a patient with a history of a kidney transplant admitted to the hospital with acute renal failure due to dehydration is assigned codes T86.19 Other Complication of Kidney Transplant, N17.9 Acute Kidney Failure Unspecified, and E86.0 Dehydration to capture the effect on the transplanted kidney with the ARF and dehydration. “Code T86.19 is assigned to capture the fact that the function of the transplanted kidney is affected by the ARF, but the transplant itself has not failed.”
1. AHA Handbook, Renal Disease, Diseases of the Genitourinary System