CKD staging

tkreilingtkreiling
in CDI Talk Archive
Can anyone tell me if you can assign the stage of CKD if you have the descriptors documented that are listed behind the code in the book, such as mild, moderate, severe? For example, assigning code 585.2 for CKD stage 2 when the physician has documented CKD, mild only. Or does he specifically need to document CKD stage 2?
Thank you,
Tara RN, CCDS

Comments

  • belnapcbelnapc
    edited April 2016
    I know that our coders will go ahead and place the code if documented CKD and mild, moderate, severe.

    Cara Belnap MS, RN, CCDS                                                       
    Lead Clinical Documentation Specialist | Health Information Management
    St. Luke's Health System | 190 E Bannock St. | Boise, ID 83712
    Phone: (208)  381-9302| Fax: 208-381-7186 | E-mail: belnapc@slhs.org

    "Always let your conscience be your guide" -- Jiminy Cricket
  • angelamckee@uh.organgelamckee@uh.org
    edited April 2016
    The descriptors you are referring to are enclosed in parentheses. Parentheses enclose
    supplementary words called nonessentials modifiers, which may be present in the
    narrative description of a disease without affecting the code assignment according to
    coding guidelines.

    Please refer to the following coding clinic 4Q 2005 pg 77-79:

    Chronic Kidney Disease


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