Coding of ESRD-Mentors wanted

cmorell

Here is the scenario:

In the H/P under History: (diagnoses in a paragraph form)...anemia secondary to chronic renal insufficiency, chronic renal failure....

This was NOT the PDx-just included in a LONG list of diagnoses.
Actually C-Diff was the PDx.

In the assessment portion of the H/P-chronic renal failure. Earlier labs note BUN 93/Creat 2.2 (GFR 31.43 on chemistry).

One day inpatient stay. No renal consult.
Discharge Summary: again, lots of diagnoses (in paragraph form not list form) ...exac of renal failure due to dehydration, ESRD...

Final Coding Summary shows MCC of ESRD. I felt that it was not clinically supported based on studying the white paper by Dr. Kennedy and the National Kidney Foundation definitions. I also thought that payers were disallowing conditions that are not medically supported. Also, I thought we do not like to code diagnoses that are ONLY on the discharge summary and not throughout the medical record (however this was only a one day stay).

Would you have coded it? Would you have queried?

Thanks CDI gurus!

robert.hodges2

Unless the patient was on dialysis you have no justification for an ESRD diagnosis. Based on what you presented the patient has labs consistent with Stage 3 chronic kidney disease which isn't even a CC. Definitely something to monitor though over time.

I would have asked for clarification on the exacerbation and the chronic component of the renal failure, using RIFLE criteria for the acute change.

Just me.

Robert

Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
 
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
 
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens

cbarnes

I might have asked for the stage of CKD for severity. I would not have asked for ESRD or ARF/AKI without more information.

dallend@einstein.edu

Was the patient on dialysis?

cmorell

No, the patient was not on dialysis. The patient's GFR 31.43 and the only mention of ESRD was ONCE in the d/c summary. The H/P said chronic renal insufficiency and chronic renal failure. When reviewing the final coding summary I was surprised to see ESRD as an MCC. I didn't feel there was clinical evidence/treatment etc. to support coding the single mention of ESRD listed only in the dc summary one time with the GFR as above and no dialysis or mention of the patient needing a kidney transplant or even further documentation of the stage of CKD. I don't usually query until day 2 in case it is only dehydration. Based on all of the info in the original post do you feel there was enough documentation from a coding perspective to code the Dx of ESRD or would you have written a retrospective query before coding the ESRD or just not coded the ESRD at all?

Thanks

dallend@einstein.edu

My understanding is that a patient has to be on dialysis in order to code ESRD. (I am at home now and do not have any of my books so I cannot provide you with the concrete information).
I would have queried to clarify the "exacerbation of renal failure due to dehydration". I have never seen that diagnosis documented in quite that manner before. In this circumstance I would have also queried for CKD stage.
At our facility, our coders will not code a diagnosis that appears on the dc summary only. They would forward the case to use for a query. In this circumstance our coders would not have coded the ESRD.

catladyrn

Not to hijack the thread or anything, but I am reviewing a case where IM (the attending) and renal have made a (secondary) dx of CKD V, but the cardiologist is calling it ESRD. They did put in an HD cath yesterday and then started HD. I am thinking that the IM and renal docs have clearly decided what they want to call it, but I know that some coders will pounce on that ESRD. Should I query? Thx,

Renee


Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center

robert.hodges2

Here my coder would go with either the attending or the nephrologist (since they are the specialist). By definition, According to RIFLE criteria, ESRD is appropriate for "Complete loss of kidney function > 3 months". Since this sounds like it's less than 3 months, I'd stick with stage 5 CKD.

You may want to talk to the coder and see how they would code it and perhaps have an educational opportunity for them. I just know that they are responsible for the final coding of the chart and that is why I tend to ask mine lots of questions and discuss issues. That's why I know how my charts are coded and it prevents some potential unnecessary queries.

Robert

Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
 
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
 
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens

pbautista

I am told by our coding supervisor if they document both to code to the highest level.

Thank You,
Pearley Bautista, RN, CCS
Coding Data Quality Manager
Enterprise Medical Coding Dept
(310) 825-4777

dvitalone1

I agree.


Dawn RN
Clinical Documentation Improvement Specialist

Unknown

We were audited on a record with documentation showing:
CKD 4, CKD 5 and ESRD.

The coder coded ESRD.

We were told 'the documentation was unclear' and we should have queried.

Charlene

catladyrn

I used to be able to talk to coders during a case at my old hospital, but it's not an option here. Unfortunately we have dozens of coders, including contract, and it could end up in the lap of any one of them, so I can't talk to them until after coding, if necessary. I'm not sure I'd accept both codes; I think it falls under conflicting documentation. If it were the nephrologist saying ESRD and the attending saying CKD V then I'd definitely query for concurrence, but I just wondered what other people felt the protocol should be when it's a consultant who's not directly involved with that body system.

Specialists...feh.

Renee


Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center

pbautista

With documentation of ckd 4 along with CKD V and ESRD, maybe unclear. I believe in the encoder CKD V is ESRD.

Thank You,
Pearley Bautista, RN, CCS
Coding Data Quality Manager
Enterprise Medical Coding Dept
(310) 825-4777



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jskagen

While CKD Stage V and ESRD may mean the same thing to some in the clinical world, in the coding world they are 2 separate codes.

585.5 = CKD Stage V
585.6 = ESRD

Here is what Coding Clinic has to say on this subject-

Chapter 10: Genitourinary system dzs coding guidelines 10/1/2008
Coding Clinic, Fourth Quarter 2008 Page: 244 to 245 Effective with discharges: October 1, 2008

10. Chapter 10: Diseases of Genitourinary System (580-629)

a. Chronic kidney disease

1) Stages of chronic kidney disease (CKD)

The ICD-9-CM classifies CKD based on severity. The severity of CKD is designated by stages I-V. Stage II, code 585.2, equates to mild CKD; stage III, code 585.3, equates to moderate CKD; and stage IV, code 585.4, equates to severe CKD. Code 585.6, End stage renal disease (ESRD), is assigned when the provider has documented end-stage-renal disease (ESRD).

If both a stage of CKD and ESRD are documented, assign code 585.6 only.

Hope this is helpful.

Julie Skagen RN BSN
CLinical Documentation Specialist
Medical Records
Bozeman Deaconess Hospital
Bozeman, MT 59715
1-406-522-1802
jskagen@bdh-boz.com

cynthia.a.goewey

585.5 would be assigned for CKD stage V unless the patient is on chronic dialysis. In the tabular list for ICD-9 585.5 (CKD, Stage V) excludes CKD, stage V requiring chronic dialysis (585.6).
Cindy