ICD 10 and Nephrology

Jeff Kaufhold, MD FACPNephrology Associates of Dayton

Oct 2013

2

Make the Diagnosis of Kidney Disease

• CriteriaThe ICD9 Code for CKD is 585.x where x = stage The ICD 9 Code for ARF is 584.9

Decreased kidney functioneGFR of <60 ml/min/1.73 m2 for ≥ 3 months

Abnormal urinalysis including the presence of proteinuria or hematuria

Request a spot urine protein/creatinine ratio(Normal is <30 mg/g)

Document an abnormal Renal Imaging Study

ICD 9 and 10 history

• ICD 9 developed by WHO• ICD 9 Clinical Modification developed for US in 1979.• CPT (clinical Procedural Terminology) codes used for

ambulatory reporting.• ICD 10 developed in 1990’s• ICD 10 codes are now available in EPIC as of Oct 1 2013• Mandatory use of ICD 10 is Oct 1, 2014.• CPT codes will continue to be used for physician

practice settings/ office billing

ICD 10 after Oct 1 2014

• Required for HIPAA transactions• ICD 10 CM (Diagnosis) codes Required for

diagnosis of all services inpt or outpt• ICD 10 PCS (procedure) codes will be required

on inpt claims• EPIC is starting the migration from ICD 9 to 10

codes now, and EPIC Premier inpt billing function includes the new ICD 10 coding structure.

ICD 10 Changes

Over 50% of new Dx are musculoskel, and 36 % are to distinguish R from L

ICD 10 Changes

• Up to 7 characters• Includes complication, severity, sequelae and

other disease related parameters• Includes laterality• Includes initial or subsequent encounter code• Improved consistency of terminology• Combination codes are common i.e DM 2,

controlled with renal manifestation• Has space holders for expansion

ICD 10 PCS coding for inpts0 D B 5 8 Z X

Section Body system

Root operation

Body part Approach Device qualifier

Med/Surg GI Excision Esophagus Natural opening, endoscopic

No device implanted

Diagnostic

ICD 9 ; 45.16 EGD with excisional biopsy, ICD 10 0DB58ZX Endoscopic esophageal excision via natural or artificial opening

Most common issues in ICD 10

• Laterality – as you code, EPIC will prompt you if right or left is required

• Trimester specific• Many new orthopedic codes• Specificity is increased dramatically, so

physician documentation must be more specific too.

Top 5 Clinical Documentation Issues

• CHF• Sepsis• Renal Failure• Pneumonia• Respiratory Failure

• Don’t use “Other” or accept a nonspecific diagnosis like DM, when a more specific term exists:

• “DM 2 controlled with renal manifestation”

ICD 10 codes

• Epic is migrating codes so over next year you may search using known ICD 9 codes

• Can keep your PMHx and ongoing problem list NONSPECIFIC,

• But your visit diagnosis list must be as specific, detailed, and include as many modifiers/ comorbidities/severity codes as possible

Common Diagnoses

• ICD 9

• 250.02 DM 2 no mention of controlled or complication

• 250.43 DM 1 with renal manifestation

• ICD 10

• E11.65 DM 2 with hyperglycemia

• E10.21 DM 1 with nephropathy AND

• E10.65 DM1 with hyperglycemia

Top 5 Clinical Documentation issues

Condition Common issues Financial impact

CHF Acute vs Chronic, systolic vs diastolic

DRG 684 Renal failure without major complication or comorbidity

Sepsis Sepsis, severe sepsis, SIRS, bacteremia

$ 3609

Renal Failure Acute vs chronicStage with RIFLE criteria or CKD stageWith ATN is important

DRG 682 renal failure with major complication and comorbidity

Pneumonia Cause / specific bacteria Aspiration, simple vs complex, laterality

$ 9340

Respiratory Failure Acute vs chronic, resp distress vs resp failure

Quality Performance hinges on Documentation

• For inpts affects the hospital quality score• For our pts affects our practice score• Lack of clear documentation results in

inappropriate assignment of complication codes for expected consequence of renal disease

• Improved documentation results in lower reported complication rates,

• higher complexity/ comorbidity scores reflect sicker population we care for.

Specific details for pts with ARF and CKD

• DM Type I or II, controlled or uncontrolled– Use A1c over 6.5 as uncontrolled– With renal manifestation

• Hypertension – With nephropathy

• CKD stages 1-5, use ESRD for pts on dialysis in the medicare ESRD program.

• AKI with ATN

Specific details for pts with ARF and CKD

• AKI with ATN– Urine findings ATN casts– Oliguria– Creatinine over 2.5 or > 2X baseline– Were they pre-renal?

• Does pt have TIN?• Complications of renal failure

– Anemia of CKD– Secondary hyperparathyroidism of renal origin– Protein calorie malnutrition Severe = albumin less

than 3.0

Estimated impact on physician practice

• 10 -20 % increase in denials• Differences in authorization and referral

triggers• Increased scrutiny of documentation• Impact on contracting/ preferred provider

status based on severity of illness as reflected in coding.

ICD 10 and EPIC

• ICD 10 diagnosis calculator goes live on Premier Epic Oct 28 2013

• Training modules available on Healthstream• Some codes require specific information, and

a coding window will open to fill in R vs L, initial visit vs followup, sequelae.

• Many codes won’t require more specificity, but for visits we should try to be as specific as possible.

ICD 10 and EPIC

• Many codes won’t require more specificity, but for visits we should try to be as specific as possible.

• We can double click item on the problem list like DM, HTN, Other disorder of renal etc, and make it more specific, without losing / deleting associations.

Diabetes codes

• E08.22 DM due to underlying condition with diabetic nephropathy

• E09.22 Drug or chemical induced DM with DM CKD

• E10.22 DM I with Diab. Neph• E11.22 DM II with Diabetic Nephropathy• E13.22 Other specified DM with Diabetic CKD

CKD Codes

• N18.1 CKD stage 1• N18.2 CKD Stage 2• N18.3 CKD Stage 3• N18.4 CKD Stage 4• N18.5 CKD stage 5• N18.6 ESRD• N18.9 CKD unspecified

CKD and DM codes

• Code the DM first, then the stage:– E10.22 Type I DM with nephropathy– N18.6 ESRD

• Same for Hypertensive Kidney Disease– I12 hypertensive Kidney disease– N18.4 CKD Stage 4– If pt has heart and kidney disease, use

• I13 hypertensive Heart and CKD– CHF uses I 50 codes

HTN and CKD Codes

• I12.0 Hypertensive CKD with Stage 5 or ESRD• I12.9 “” “” with stages 1-4 CKD• I13.10 Hypertensive Heart and CKD without

heart failure, Stages 1-4• I13.11 Hypertensive Heart and CKD without

heart failure, Stage 5 or ESRD• I13.2 Hypertensive Heart and CKD with heart

failure, Stage 5 or ESRD

Nephrology Codes

• N 0 – 8 Glomerulonephritis• N 10 Interstitial Nephritis• N 17 ARF• N 18 CKD• N 20 Kidney stone• N 30-39 Bladder disorders• N 40 BPH

– ICD10Data.com

Nephrology Codes

• PCKD Q 61.3• Acquired cyst N 28.1• Q 60-64 Congenital Malformations of the

urinary System• R 80 Proteinuria• R 81 Glycosuria• R 60 Edema

– ICD10data.com

Nephrology Codes for ICD 10

• Electrolyte disorders: E 87– High K E 87.5

• Protein Calorie Malnutrition– E 43 severe– E 44 Mild to Moderate

• Secondary hyperparathyroidism of renal origin– N 25.81

Nephrology Common Codes

• Anemia of CKD D 63.1• Lupus Nephritis

– SLE M 32 – not completely mapped yet

• Renal transplant – has not yet mapped– (as of Oct 2013)– Dysfunction would be coded with the ARF or CKD

code to denote pts renal function at time of visit• N 17.9 ARF• N 18.3 CKD stage 3

Transplant Specifics

• Just because your patient has a transplant, they still have Chronic Kidney disease.– List the transplant– List the CKD stage for chronic allograft dysfunction– List acute allograft dysfunction if present– List the cause of their underlying CKD/ESRD– List comorbidities and complications

• Are they anemic due to Cellcept use?• Did they develop NODAT?

Doc talk, Precyse University, Oct 2013

PCKD specifics

• PCKD Q 61.3• Acquired cyst N 28.1• Q 60-64 Congenital Malformations of the

urinary System• Autosomal Dominant or recessive?• Liver /other cysts?