HTN + CKD + CHF combo code


Please help me with this case: patient with history of HTN, CHF and CKD presented with HTN urgency and AKI. My colleague asked me whether he can make the combo code as a principal diagnosis ? I am not sure what to say. What I know is a patient with HTN, CKD and CHF presented with acute on chronic CHF, I can make the combo code as a principal Dx. Would you please help us to resolve this dilemma ?



  • The sequencing htn/ckd/hf as pdx depends on code first instructional notes (ie. I50 codes and esrd instructional notes), Official Coding Guidelines discusses it, as does Coding Clinics.

    If this patient had acute on chronic HF on arrival and it meets the definition of the principal, per official coding gudielines regarding the selection of principal diagnosis, then the combo code would be the principal based on code 1st requirements.

  • The answer to this depends entirely on the documentation. IF the documentation indicates patient presented with pulmonary edema AND has documented acute on chronic HF AND the patient was treated with IV diuretics, then a case might be made for the HTN/HF - if there is not an alternative etiology of HF documented. Depending on clinical indicators and clarity in documentation regarding cause of pulmonary edema (a/c HF v HTNsive urgency) there may be a possibility of considering HTN/HF/CKD as PDX. Look for documentation indicating CHF exacerbation caused by the HTNsive urgency v. linking language establishing causation directly between the HTNsive urgency and the pulmonary edema. It can be super tricky. The key really is going to be the context of documentation, and the focus of care and use of resources. It's impossible to tell with just the information above but look at the clinical indicators, look at the provider documentation. Did they indicate the reason for admission? If not and clinical indicators support it, a query for reason for admission might be supported.

    Things to look for:

    BNP 500 (in general - if morbid obesity, this value may be lower; in setting of CKD, it can be elevated from that condition as well)

    Pedal/pulmonary edema

    SOB/dyspnea/chest pain

    Lung sounds - Rales/rhonchi

    Chest XR with pulmonary edema, congestion

    Treatment with IV diuretics with po meds like entresto, ACE/ARBs, po diuretics

    It's impossible to comprehensively cover all the possibilities here.

    Remember that if cause of HF is indicated to be other than hypertension, assumed causal relationship between HTN and HF is unlinked so in cases with ICM and HF or valvular disease, HOCM, alternative causes of cardiomyopathy, opportunity may exist to increase precision in these cases.

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