Q&A: Coding chronic kidney disease, hypertension, and diabetes mellitus

Q: Let’s say a provider documented chronic kidney disease (CKD), 2/2 hypertension (HTN), and diabetes mellitus (DM), and the stage of CKD was not specified, but lab results show patient was in stage 2. Could I assign codes for CKD, stage unspecified, Hypertensive CKD w/ stage 1-4, and Type II DM. Do I need to assign a separate code for HTN?

A: Let’s break down the documentation.

CKD secondary to HTN and DM: With this documentation, we have two combination codes to assign—hypertensive CKD and diabetic CKD. We would also assign a code to reflect the stage of the CKD.

So, let’s say the patient has diabetes type 2, CKD, and HTN. The codes you would assign are:

• Type 2 diabetes with CKD—E11.2
• Hypertensive CKD—I12.9 (with stage 1-4 and unspecified CKD)

If the provider did not specify the stage of CKD, we would assign the code for CKD unspecified—N18.9. But as a CDI specialist, you’re likely going to query for the stage based on the labs.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.