Q&A: Documentation of CKD and ESRD

Q: If physician documents Stage 5 chronic kidney disease (CKD) and end-stage renal disease (ESRD) on peritoneal dialysis, do I code them both or do I need to query?

A: As CDI specialists, we should always make sure that every patient has a true and accurate chart, so anytime there is conflicting information present in the chart it would be appropriate to query the attending provider for clarification.  

According to the National Kidney Foundation, CKD (chronic kidney disease), also known as chronic renal failure [CRF) describes gradual loss of kidney function over time (defined as three months or greater). The stage of CKD is based on the patient’s level of glomerular filtration rate (GRF), which is a measure of the filtering capacity of the kidneys. The patient’s GRF is calculated using a patients age, gender and their serum creatinine level. There are five stages of kidney disease. The difference between CKD Stage 5 and ESRD is the dependence on dialysis. A patient with CKD Stage 5 may or may not be on dialysis and the damage to the kidney may be reversible. A patient with the diagnosis of ESRD requires chronic dialysis.

Per the Official Guidelines for Coding and Reporting, Section I.C.14a.1, If both a stage of CKD and ESRD are documented, the coding professional would assign code N18.6 (ESRD) only.

Editor’s Note: Sharme Brodie, RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.