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From HIM: Documenting tips for chronic kidney disease

23 Dec 2018

Avoid using ranges such as CKD 3-4

By: Toni Salchenberg RN, BSN, CCDS

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When chronic kidney disease is documented as a range such as CKD 3-4, it often results in a query back to you for clarification. When one specific stage is documented such as CKD 3 or CKD 4, no query is needed.

The staging levels are located in the Salem Hospital standard definitions. The Salem Health definition is below.

Chronic renal failure (codes are the same as for chronic kidney disease) is a kidney disorder (nephropathy) manifested by radiological or urinary abnormalities such as proteinuria, hematuria or by a GFR less than 60 for more than three months.

CKD staging levels 1-5 are defined by the estimated GFR:

Level   Estimated GFR
 1   >90
 2   60-89
 3   30-59
 4   15-29
 5   <15 or on dialysis chronically is called end-stage renal disease (ESRD) and codes that way.

Documentation notes

  1. The term chronic renal insufficiency has little meaning to coders and does not affect the severity of illness or risk of mortality. Rarely would the term “insufficiency” accurately describe kidney disease (to coders or to anyone else).
  2. Documenting chronic renal failure without the stage codes only to CRF/CKD unspecified and is neither a CC nor an MCC.

Please document the underlying cause (or suspected underlying cause) whenever possible such as diabetes, hypertension, polycystic kidney disease, etc.