Chronic Kidney Disease

Definition

A persistent and usually progressive, irreversible loss of kidney function.

• Abnormalities are usually present > 3 months per KDIGO.
• Often associated with:

• Diabetes
• HTN
• Urinary obstruction
• Autoimmune diseases
• Recurrent UTIs
• Prior episodes of AKI

Medications such as ASA, acetaminophen, NSAIDS and some antibiotics can cause renal damage and lead to CKD.

Diagnostic Criteria

The diagnostic criteria for CKD is the presence of either of the following for > 3 months:

• Decreased GFR <60 ml/min, OR
• Objective measure of kidney damage-significant persistent albuminuria, hematuria, structural abnormalities noted on imaging.
• CKD stages 1 or 2 require the presence of one or more markers of kidney damage. A GFR >/= 60 is not CKD if there are no markers noted.
• CKD stages 3-5 are based on GFR alone.

Coding & CDI Considerations

• When a patient is admitted primarily for fluid overload necessitating emergent dialysis, assign E87.70 (fluid overload) as the principal diagnosis.
• There is an assumed relationship between:

• Hypertension and chronic kidney disease (CKD)
• Hypertension, heart failure, and chronic kidney disease (CKD)
• Diabetes and chronic kidney disease (CKD)

• ‘CKD5 requiring chronic dialysis’ codes to N18.6 (ESRD) per Excludes1 note.
• Patients receiving dialysis for ESRD should be assigned both N18.6 (ESRD) and Z99.2 (dependence on dialysis).
• Consider the following:

• Official Coding Guidelines I. C.14.a.2
• AHA Coding Clinic 2023 First Quarter, p. 19: ESRD and Fluid Overload

• The stage of CKD should not be assigned until glomerular filtration rate (GFR) and/or creatinine (Cr) levels have stabilized. This is especially important in cases of acute kidney injury (AKI) superimposed on CKD, where staging may not be reliable until renal function has returned to baseline. In such scenarios, it is not appropriate to query for CKD staging.
• All patients with a history of kidney transplantation meet the definition of CKD, regardless of current GFR. However, CKD alone does not indicate a transplant complication and should not be coded as such unless explicitly documented.
• For patients with end-stage renal disease (ESRD) on dialysis, a diagnosis of AKI should not be assigned, as renal function is already non-recoverable.
• When applying Sepsis-3 criteria (SOFA score) in patients with CKD, always consider the patient’s baseline creatinine to avoid misclassification of organ dysfunction.
• Comorbidity and Risk Adjustment:

• CKD Stages 4 and 5 are classified as Complications or Comorbidities (CCs).
• CKD Stages 3–5 and ESRD are recognized Hierarchical Condition Categories (HCCs) under CMS-HCCs 326–329.

• The terms “chronic renal insufficiency,” “chronic renal failure,” and “chronic renal disease” are clinically acceptable and may be used interchangeably with CKD for coding purposes.

Query Opportunity

• When documentation reflects "CKD 3/4," a clarification query should be initiated to specify either Stage 3 (a or b), or Stage 4 CKD. Historical laboratory values may be referenced to support staging.
• Providers may continue to document ESRD in patients who are post–kidney transplant (s/p transplant). However, if the patient is no longer dialysis-dependent, the code N18.6 (ESRD) should not be assigned. Instead, review for the current CKD stage, querying as necessary and include Z94.0 (kidney transplant status).
• When CKD is documented, review clinical indicators and query for a stage, as appropriate.

Looking for CDI help?

Learn more about e4health CDI Solutions. Our Team is leading the way in the CDI industry.

e4health CDI Education

Need help to earn CEUs or education for your team? Visit the IQ Education Center and get your free account or contact us for more information.

e4health is dedicated to elevating the business of healthcare. We are committed to offering support and the most current information and updates to collaborate with coding and CDI professionals to realize their fullest potential. We enthusiastically seek opportunities to develop ourselves and each other. We understand that knowledge is the key to success for our clients by navigating the ever-changing health information management landscape.

CDI Leadership Roundtable

Earn FREE ACDIS CEUs when you join Staci Josten, RN, BSN, CCDS, Alyson Swinehart, BSN, RN, CCDS, and other CDI leaders for a roundtable discussion regarding important, timely industry topics! The topic for April’s discussion is The CDI Sweet Spot: Balancing Quality, Quantity, and Technology. We will provide background on this topic, share industry insights, and facilitate collaborative discussion with guided questions and answers.

What is the e4health CDI Leadership Roundtable?

The goal for the virtual CDI Leadership Roundtable Discussion is for CDI leaders to explore specific topics within CDI, learn about the topic and from each other. During each roundtable, e4health CDI Leader’s will present a CDI topic, spend time sharing current industry standards or some education regarding this topic and then open with probing questions for group discussion.

Who should attend the e4health CDI Leadership Roundtable?

The focus of this group is for those who have influence over CDI program process, policy, and education.

Why should I attend the e4health CDI Roundtable?

This will be a wonderful place to learn, share your wins and challenges and collaborate with other CDI leaders across the industry. Also, after completing a survey, free ACDIS CEUs will be earned.

The information and opinions presented here are based on the experience, training, and interpretation of the author. Although the information has been researched and reviewed for accuracy, e4health does not accept any responsibility or liability regarding errors, omission, misuse, or misinterpretation. This information is intended as a guide; it should not be considered a legal/consulting opinion or advice.