ICD 10 and Nephrology How to find ARF and CKD For Coders and Clinical Documentation Specialists

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ICD 10 and NephrologyHow to find ARF and CKDFor
Coders and Clinical Documentation Specialists

• Jeff Kaufhold MD FACP
• Nephrology Associates of Dayton
• Oct 2013

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Summary

• Review of the development of ICD 10
• Changes coming with ICD 10
• Top 5 Clinical Documentation Issues
• Making the Diagnosis of ARF and CKD
• ICD 10 codes for renal disease
• RIFLE criteria for Acute renal Failure
• Progression of CKD and CKD stages
• How to differentiate Acute from Chronic

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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 1990s
• 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

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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.

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ICD 10 Changes
Over 50 of new Dx are musculoskel, and 36 are
to distinguish R from L
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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

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ICD 10 PCS coding for inpts
0 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
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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.

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Top 5 Clinical Documentation Issues

• CHF
• Sepsis
• Renal Failure
• Pneumonia
• Respiratory Failure
• Dont use Other or accept a nonspecific
  diagnosis like DM, when a more specific term
  exists
• DM 2 controlled with renal manifestation

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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

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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

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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 chronic Stage with RIFLE criteria or CKD stage With 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
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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.

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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.

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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 wont require more specificity, but
  for visits we should try to be as specific as
  possible.

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ICD 10 and EPIC

• Many codes wont 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.

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Make the Diagnosis of Kidney Disease

• Criteria
• The ICD9 Code for CKD is 585.x where x stage
• The ICD 9 Code for ARF is 584.9
• Decreased kidney function
• eGFR of lt60 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 lt30 mg/g)
• Document an abnormal Renal Imaging Study

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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

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Specific details for pts with ARF and CKD

• AKI with ATN
• Urine findings ATN casts
• Oliguria
• Creatinine over 2.5 or gt 2X baseline
• Were they pre-renal?
• Does pt have TIN?
• Look for eosinophils in blood or urine
• Complications of renal failure
• Anemia of CKD
• Secondary hyperparathyroidism of renal origin
• Protein calorie malnutrition Severe albumin
  less than 3.0

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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

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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

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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

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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

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The Early NHANES III StudyAnalysis of Prevalence
of CKD by Stage
Stage Description eGFR Range (ml/min/ 1.73 m2) Population (1,000s) Population ()
1 Kidney damage with normal or increase GFR 90 5,900 3.3
2 Mildly decreased GFR 60-89 5,300 3.0
3 Moderately decreased GFR 30-59 7,600 4.3
4 Severely decreased GFR 15-29 400 0.2
5 Kidney Failure lt 15 300 0.1
- Adapted from NHANES III (2000)
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US Population with CKD
Coresh, Selvin, Stevens. Prevalence of CKD in the
US. JAMA.2007298(17)2038.
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A Large National Burden in 2009The Renal
Continuum of Care
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Cardiovascular events by Stage of CKD
NKF KDOQI guidelines www.kidney.org/professionals
/KDOQI/guidelines_ckd/toc.htm
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All Cause Mortality By Stage of CKD
NKF KDOQI guidelines www.kidney.org/professionals
/KDOQI/guidelines_ckd/toc.htm
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Why Do CKD Patients Need Special Care?Renal
Disease Care is Expensive
10 of Federal Healthcare Costs
1.5 of Patients
ESRD Late Stage Chronic Kidney Disease (CKD)
30B peryear
Other Medicare
Other Medicare
Source USRDS (publicly available comprehensive
clinical and financial dataset reported to and
used by CMS) 375,000 ESRD 300,000 Stage 4
Chronic Kidney Disease
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Timely Referral Long-lasting benefits

• Late Referral patients have a 44 higher risk of
  mortality in the first year of dialysis compared
  to Early Referral patients

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Who Should be Screened for CKD?

• The AT RISK Population
• HYPERTENSION
• DIABETES MELLITUS
• CARDIOVASCULAR DISEASE
• FAMILY HISTORY OF CKD

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Screening Recommendations

• Screening Should Include
• Laboratory studies to include serum creatinine
  and eGFR
• Urinalysis to determine the presence of
  proteinuria
• Imaging studies such as ultrasound
• Screening recommendations are provided in KDOQI,
  Guideline 1
• http//www.kidney.org/professionals/kdoqi/guidelin
  es_ckd/toc.htm

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Presence of MAU Indicates a Potential Increased
Risk for CV Events
1,000
900
Macroalbuminuria gt300 mg/day Increased CV Risk
and Presence of Renal and Vascular Dysfunction
800
700
600
Urinary Albumin (mg/day)
500
400
300
MAU 30-299 mg/day Increased CV Risk and
Vascular Dysfunction
200
100
0
Normal
Cardiovascular Risk
Garg JP et al. Vasc Med. 2002735-43. Eknoyan G
et al. Am J Kidney Dis. 200342617-622.
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Make the Diagnosis of Kidney Disease

• Criteria
• The ICD9 Code for CKD is 585.x where x stage
• The ICD 9 Code for ARF is 584.9
• Decreased kidney function
• eGFR of lt60 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 lt30 mg/g)
• Document an abnormal Renal Imaging Study

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How to Implement Timely Referral?

• Establish CKD diagnosis and Details
• Make a specific renal disease diagnosis if
  possible
• Identify co-morbidities
• Hypertension
• Diabetes
• Cardiovascular Disease
• Determine the severity of CKD (know the eGFR)
• Identify CKD Complications
• Anemia (know the Hgb)
• Secondary Hyperparathyroidism (know the Ca and
  Phos)
• Malnutrition (know the albumin)
• Assess stability of Kidney Function and CKD Stage
• Recommendations for further evaluation are
  outlined in KDOQI Guideline 2
• http//www.kidney.org/professionals/kdoqi/guidelin
  es_ckd/toc.htm

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Timely Referral Decision Making

• Timely Referral Guidance
• Rapidly decreasing renal function ?REFER
• Abnormal eGFR AND proteinuria ? REFER
• eGFR 30 ml/min/ 1.73 m2 ? REFER
• eGFR lt60 ml/min/1.73 m2 and Cardiovascular
  Disease Present ? REFER
• Uncontrolled Hypertension Present ? REFER

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Reason for Nephrology Consultationin the
Hospitalized patient
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15
60
Ref Paller Sem Neph 1998, 18(5), 524.
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Acute Dialysis Quality Initiative

• RIFLE Criteria Helps risk stratify patients with
  acute renal failure.
• Increased mortality seen with increases in
  creatinine of 0.3 to 0.5 mg/dl
• 70 increase for all inpts,
• 300 increase in cardiac surgery pts

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Acute Renal Failure

• Definition may depend on whom you ask
• Surgeon - - low urine output
• Intensivist-- severe acidemia
• Nephrologist-- rising serum creatinine
• Frequency - depends on clinical setting
• 1 of all admissions to hospital
• 2-5 of all individuals during a hospitalization
• 4-15 during cardiopulmonary bypass
• 10-30 of all admissions to ICU

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Definition

• a sudden and severe decrease in the glomerular
  filtration rate (GFR) sufficient to cause
  increases in BUN and Scr (azotemia), Na/H2O
  retention (edema), and development of acidemia
  and hyperkalemia
• review of 27 studies showed no 2 used the same
  definition chronic renal confusion

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Whats in a name?

• lack of a universally recognized definition of
  ARF
• 2004 consensus conference
• proposed the term acute kidney injury (AKI) to
  reflect the entire spectrum of ARF recognizing
  that an acute decline in kidney function is often
  secondary to an injury that causes functional or
  structural changes in the kidneys

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Newest DefinitionMehta CritCare 2007

• An abrupt (within 48 h) reduction in kidney
  function currently defined as
• an absolute increase in serum creatinine of
  either gt 0.3 mg/dl,
• or a percentage increase of gt 50 or a
  reduction in UOP (documented oliguria of lt 0.5
  ml/kg per h for gt 6)

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RIFLE criteria

• Risk low uop for 6 hours, creat up 1.5 to 2 times
  baseline
• Injury creat up 2 to 3 times baseline, low uop
  for 12 hours
• Failure Creat up gt 3 times baseline or over 4,
  anuria
• Loss of Function Dialysis requiring for gt 4 weeks
• ESRD Dialysis requiring for gt 3 months

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RIFLE estimate of Mortality

• Two studies Uchino Hoste
• No renal failure 4.4 5.5
• Risk 15 8.8
• Injury 29 11.4
• Failure 53.9 26
• Loss of Function
• ESRD

Crit Care Med 2006 341913-7, Hoste CCM 2006
10R73
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RIFLE criteria

• When markers of severity of illness are looked at
  excluding renal data, no difference in groups is
  seen.

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The differential for any lab abnormality is

• Lab error
• Lab error
• Lab error
• Iatrogenic
• Polypharmacy
• Real disease
• IN THIS ORDER!

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Acute renal failure (ARF)

• Differential for Lab abnormality Causes
• A rise in the BUN level can occur without renal
  injury, such as in GI or mucosal bleeding,
  steroid use, or protein loading (such as IV
  nutrition)
• A rise in the creatinine level can result from
  medications (eg, cimetidine, trimethoprim) that
  inhibit the kidneys tubular secretion, or an
  increase in creatinine production such as seen in
  Rhabdomyolysis. (muscle breakdown)
• True Anuria is most commonly the result of an
  obstructed foley catheter, or an error in
  recording output. The worst cause of anuria is
  cortical necrosis.

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Acute renal failure (ARF)

• An abrupt or rapid decline in renal function
• Marked by a rise in BUN (azotemia) or serum
  creatinine concentration
• Immediately after a kidney injury, BUN or
  creatinine levels may be normal
• The only sign of a kidney injury may be decreased
  urine production
• Use RIFLE Criteria to evaluate Risk.

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Acute renal failure (ARF)

• History and Physical examination
• Nephrotoxic drug ingestion
• History of trauma or unaccustomed exertion
• Blood loss or transfusions
• Congestive heart failure
• Exposure to toxic substances, such as ethyl
  alcohol or ethylene glycol

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Acute renal failure (ARF)

• History and Physical examination
• Exposure to mercury vapors, lead, cadmium, or
  other heavy metals, which can be encountered in
  welders and miners
• Hypotension
• Volume contraction
• Vomiting/Diarrhea/Sweating/Nursing Home
• Evidence of connective tissue disorders or
  autoimmune diseases

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Pathophysiology

• ARF may occur in 3 clinical patterns

BUNCr gt 201
BUNCr 10-201
BUNCr gt 201
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Pathophysiology

• ARF may occur in 3 clinical patterns
• Suggested by labwork

BUNCr gt 201 Pre-Renal or Post-Renal
BUNCr 10-201 Intra-Renal
BUNCr lt 101 Extrinsic Production of Creatinine
(rhabdomyolysis), this pattern also seen
in dialysis patients)
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Prerenal ARF

• Prerenal ARF represents the most common form of
  kidney injury and often leads to intrinsic ARF if
  it is not promptly corrected
• From any form of extreme volume loss
• GI, renal (Vomiting, Diarrhea, diuretics,
  polyuria), cutaneous (eg, burns), and internal or
  external hemorrhage can result in this syndrome
• Systemic vasodilation or decreased renal
  perfusion
• Anesthetics
• Drug overdose
• Heart failure
• Shock (eg, sepsis, anaphylaxis)

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Approach to ARF

• Pre-Renal
• Most common
• Due to NPO, Diuretics, ACE inhibitors, NSAIDS
• Due to renal artery disease, CHF with poor EF.
• Usually BUN / creat ratio over 20.
• Usually creat lt 2.5

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Approach to ARF

• Intra-Renal
• Most commonly pre-renal tipping over into true
  renal injury.
• Acute Tubular Necrosis is result (70)
• Tubulo-Interstitial Nephritis (20)
• Acute vasculitis/GN rare (5-10 )

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Intrinsic Renal Failure

• Intrinsic ARF
• acute tubular necrosis
• acute interstitial nephritis
• acute glomerulonephritis
• acute vascular syndromes
• intratubular obstruction
• BUNCreat ratio 10-20 1
• In Pre-renal ARF, once creat is gt 2.5, there is
  some degree of ATN

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Intrinsic ARFUrinalysis

• Intra-Renal
• Acute Tubular Necrosis (70)
• Dirty brown casts, low UOP
• Tubulo-Interstitial Nephritis (20)
• Eosinophils in blood or urine,
• Potassium out of proportion to creat.
• Normal BP, related to drug exposure
• Acute vasculitis/GN rare (5-10 )
• Proteinuria, hematuria, RBC casts

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Approach to ARF

• Post- Renal
• Most commonly due to obstruction at bladder
  outlet
• Prostate problems
• Neurogenic bladder
• Stone
• Urethral stricture (esp after CABG)

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Acute Renal failure
Complications of acute renal failure
Hyperkalemia (? ECG abnormalities) Decreased
bicarbonate (acidosis) Elevated urea Elevated
creatinine Elevated uric acid Hypocalcaemia Hyp
erphosphatemia Accumulation and toxicity of
medications secreted by the kidney
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Documentation for ARF

• List the ARF N17.9
• Cause of the ARF (ATN N17.0)
• Underlying CKD with stage if present N18.X
• Volume status
• Volume overloaded E 87.7 or dry E 86
• Electrolyte abnormalities
• Hyperkalemia E 87.5 / hyponatremia E 87.1
• Acid base status acidosis E 87.2 or alkalosis
  E 87.3
• Estimated GFR lt 30 ml/min means many meds need
  to be adjusted

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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
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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?

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One common Cause of ARF

• Contrast Induced nephropathy CIN

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Risk Factors for Contrast Nephropathy

• Age over 60
• Diabetes
• Pre-Renal States
• CHF
• NSAIDS, ACE Inhibitors, Diuretics
• Proteinuria Includes, but not limited to
  Myeloma.
• Pre-existing Renal Disease

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Risk of CN By Stage of CKD
lt 20 ml/min 20 30 30 60
gt 60
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CKD Stages

• Stage 1. Normal function with known dz
• Stage 2. GFR 60-80
• Stage 3. GFR 30-60
• Stage 4. GFR 15-30.
• Stage 5. GFR less than 15.
• Stage 6. ESRD on dialysis.

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Progression of CRF
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How do you differentiate ARF from CRF.

• What physical exam finding tells you the pt has
  Chronic Kidney Disease?
• What Would you see on renal Imaging for a pt with
  CKD?

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Lindseys Nails
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Acute vs Chronic Renal Failure
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Atrophic Kidney on CT