ICD 10 and Nephrology Jeff Kaufhold MD FACP

ICD 10 and Nephrology Jeff Kaufhold, MD FACP Nephrology Associates of Dayton Oct 2013

Make the Diagnosis of Kidney Disease • Criteria The ICD 9 Code for CKD is 585. x where x = stage The ICD 9 Code for ARF is 584. 9 § Decreased kidney function e. GFR of <60 ml/min/1. 73 m 2 for ≥ 3 months § Abnormal urinalysis including the presence of proteinuria or hematuria § Request a spot urine protein/creatinine ratio (Normal is <30 mg/g) § Document an abnormal Renal Imaging Study 2

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 1990’s • 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

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.

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

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

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 No device Diagnostic opening, implanted endoscopi c ICD 9 ; 45. 16 EGD with excisional biopsy, ICD 10 0 DB 58 ZX Endoscopic esophageal excision via natural or artificial opening

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.

Top 5 Clinical Documentation Issues • • • CHF Sepsis Renal Failure Pneumonia Respiratory Failure • Don’t use “Other” or accept a nonspecific diagnosis like DM, when a more specific term exists: • “DM 2 controlled with renal manifestation”

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

Common Diagnoses • ICD 9 • ICD 10 • 250. 02 DM 2 no mention of controlled or complication • E 11. 65 DM 2 with hyperglycemia • 250. 43 DM 1 with renal manifestation • E 10. 21 DM 1 with nephropathy AND • E 10. 65 DM 1 with hyperglycemia

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, 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

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.

Specific details for pts with ARF and CKD • DM Type I or II, controlled or uncontrolled – Use A 1 c 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

Specific details for pts with ARF and CKD • AKI with ATN – Urine findings ATN casts – Oliguria – Creatinine over 2. 5 or > 2 X baseline – Were they pre-renal? • Does pt have TIN? • Complications of renal failure – Anemia of CKD – Secondary hyperparathyroidism of renal origin – Protein calorie malnutrition Severe = albumin less than 3. 0

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.

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 won’t require more specificity, but for visits we should try to be as specific as possible.

ICD 10 and EPIC • Many codes won’t 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.

Diabetes codes • E 08. 22 DM due to underlying condition with diabetic nephropathy • E 09. 22 Drug or chemical induced DM with DM CKD • E 10. 22 DM I with Diab. Neph • E 11. 22 DM II with Diabetic Nephropathy • E 13. 22 Other specified DM with Diabetic CKD

CKD Codes • • N 18. 1 CKD stage 1 N 18. 2 CKD Stage 2 N 18. 3 CKD Stage 3 N 18. 4 CKD Stage 4 N 18. 5 CKD stage 5 N 18. 6 ESRD N 18. 9 CKD unspecified

CKD and DM codes • Code the DM first, then the stage: – E 10. 22 Type I DM with nephropathy – N 18. 6 ESRD • Same for Hypertensive Kidney Disease – I 12 hypertensive Kidney disease – N 18. 4 CKD Stage 4 – If pt has heart and kidney disease, use • I 13 hypertensive Heart and CKD – CHF uses I 50 codes

HTN and CKD Codes • I 12. 0 Hypertensive CKD with Stage 5 or ESRD • I 12. 9 “” “” with stages 1 -4 CKD • I 13. 10 Hypertensive Heart and CKD without heart failure, Stages 1 -4 • I 13. 11 Hypertensive Heart and CKD without heart failure, Stage 5 or ESRD • I 13. 2 Hypertensive Heart and CKD with heart failure, Stage 5 or ESRD

Nephrology Codes • • N 0 – 8 Glomerulonephritis N 10 Interstitial Nephritis N 17 ARF N 18 CKD N 20 Kidney stone N 30 -39 Bladder disorders N 40 BPH – ICD 10 Data. com

Nephrology Codes • PCKD Q 61. 3 • Acquired cyst N 28. 1 • Q 60 -64 Congenital Malformations of the urinary System • R 80 Proteinuria • R 81 Glycosuria • R 60 Edema – ICD 10 data. com

Nephrology Codes for ICD 10 • Electrolyte disorders: E 87 – High K E 87. 5 • Protein Calorie Malnutrition – E 43 severe – E 44 Mild to Moderate • Secondary hyperparathyroidism of renal origin – N 25. 81

Nephrology Common Codes • Anemia of CKD D 63. 1 • Lupus Nephritis – SLE M 32 – not completely mapped yet • Renal transplant – has not yet mapped – (as of Oct 2013) – Dysfunction would be coded with the ARF or CKD code to denote pts renal function at time of visit • N 17. 9 ARF • N 18. 3 CKD stage 3

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

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?