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Correct classification of chronic kidney disease

From the September ACP Hospitalist, copyright © 2011 by the American College of Physicians

By Richard D. Pinson, FACP

Sidebar: Ask Dr. Pinson

As the U.S. population ages, chronic kidney disease (CKD) is becoming more and more prevalent. Some common conditions predispose patients to develop CKD. Recognition and early management of CKD are crucial to limiting progression and reducing the associated morbidity and mortality.

The diagnosis of CKD and documentation of stage are important for correct coding, which affects hospital revenue and severity of illness classification. In addition, reporting the stage of CKD will improve the accuracy of our national health care database, which is important for research and for projections of national health care needs.

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Clinical practice guidelines for CKD have been published by the National Kidney Foundation. The guidelines identify five stages of CKD (see box) based on the glomerular filtration rate (GFR). End-stage renal disease (ESRD) is defined as dialysis-dependent CKD stage 5.

The GFR may be calculated using the Modification of Diet in Renal Disease (MDRD) formula, available on the National Kidney Foundation website. The calculated GFR is proportional to serum creatinine, but also depends on age, race, and gender. Most clinical labs now report calculated GFR together with serum creatinine levels. It is not necessary to perform a 24-hour urine collection to measure creatinine clearance, even though this may be a more precise measure of GFR if done correctly.

The stage of CKD can only be correctly assigned when renal function (and therefore serum creatinine levels) is at a stable baseline. If there is any acute component to a patient's renal disease, wait until renal function is stabilized, or use the prior baseline.

Although the clinical significance and associated risks of CKD begin to accelerate at stage 3, Medicare does not assign significant comorbid status until stage 4 (see box). If the stage is unspecified it won't be considered significant comorbidity. ESRD rarely goes undocumented and clearly represents even greater severity than other stages of CKD.

Always use the currently accepted clinical terminology of “chronic kidney disease” or CKD. Avoid nonspecific, imprecise terminology such as “renal insufficiency” or “chronic renal insufficiency (CRI)” as the appropriate codes for CKD will not be assigned.

In summary, always review the calculated GFR associated with the creatinine level on clinical lab reports. Documentation of any stage of CKD is important; documentation of stage 4 or 5 is crucial for correct coding, hospital reimbursement and classification of CKD patients' severity of illness. Remember, the CKD stage can only be determined when renal function (and creatinine levels) are stable; otherwise, a prior baseline stage can be used for documentation purposes.

Richard Pinson, FACP, is a certified coding specialist and co-founder of HCQ Consulting in Houston. This content is adapted with permission from HCQ Consulting.

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Ask Dr. Pinson

Q: Can one code for severe sepsis if a physician documents sepsis and acute renal failure but does not document severe sepsis?

A: The short answer is yes. Section I.C.1.b. of the 2011 Official Coding Guidelines states, in part, the following:

1. Severe sepsis generally refers to sepsis with associated [emphasis added] acute organ dysfunction.
2. If a patient has sepsis and acute organ dysfunction, but the medical record documentation indicates that the acute organ dysfunction is related to a medical condition other than the sepsis, do not assign code 995.92, severe sepsis.
3. If the documentation is not clear as to whether acute organ dysfunction is related to the sepsis or another medical condition, query the clinician.
4. Septic shock indicates the presence of severe sepsis. Code 995.92, severe sepsis, must be assigned with code 785.52, septic shock.

The above guidelines indicate that clinicians do not have to specifically document “severe sepsis.” Also, the word “associated” indicates that acute organ dysfunction (when documentation is clear and consistent) does not have to be specifically linked to sepsis for assignment of code 995.92, severe sepsis.

Always assign 995.92, severe sepsis, whenever septic shock is documented and also assign code 785.52, septic shock. Do not assign code 995.92, severe sepsis, if acute organ dysfunction in the presence of sepsis is specifically attributed to another condition (for example, “acute renal failure due to dehydration”). If documentation is unclear or inconsistent, ask the clinician.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated