Q&A: Reporting diabetes, CKD, and HTN in ICD-10-CM

CDI Strategies - Volume 13, Issue 51

Q: We had a patient with Type 2 diabetes who was admitted for hypoglycemia with metabolic encephalopathy. The patient also had stage 2 chronic kidney disease (CKD) and a diagnosis of hypertension (HTN). Which ICD-10-CM codes should we assign for this patient’s encounter?

A: ICD-10-CM assumes a cause-and-effect relationship between CKD and HTN, as well as CKD and diabetes.

CKD is most likely related to both the HTN and the diabetes when all three conditions are present. High blood pressure and high blood sugar in the blood vessels can lead to the deterioration of the vessels, which can then cause damage to the kidneys.

CKD should not be assigned as hypertensive if the provider’s documentation specifies that the CKD is not related to the hypertension. Always query if the physician’s documentation seems unclear, but based on the information given, I would report the following ICD-10-CM codes for this patient’s encounter:

  • E11.649, Type 2 diabetes mellitus with hypoglycemia without coma
  • G93.41, metabolic encephalopathy
  • E11.22, Type 2 diabetes mellitus with diabetic CKD
  • I12.9, hypertensive CKD with stage 1 through 4 CKD, or unspecified CKD
  • N18.2, CKD, stage 2 (mild)

Editor’s note: This article originally appeared in JustCoding. Sarah Humbert, RHIA, coding and compliance manager at KIWI-TEK LLC, and Temeka Davis, RHIT, coding manager at KIWI-TEK LLC, answered this question during HCPro’s webinar Simplify Complex ICD-10-CM Coding for Diabetes.

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