Q&A: Coding a history of ESRD

Q: In a case where the patient has a history of end-stage renal disease (ESRD) documented, why would ESRD be coded as a secondary diagnosis?

A: The trouble here is that pesky wording “history of,” since documentation isn’t always clear as to how the given condition relates to the current episode of care. For example, I once worked with a nephrologist who, when consulted for an acute renal failure, would begin his consult note with the words, “History of Acute Kidney Injury (AKI).” Additional documentation in the medical record, however, illustrated that the AKI was an acute and active issue.

It’s similar to the ongoing problem of determining what the doctor means when they state, “history of pancreatic cancer.” We are left to ask whether the cancer was removed and cured or whether it’s a current condition. I teach providers not to use this wording but if they feel compelled, I suggest they use qualifiers such as “remote” or “resolved” history to describe a condition no longer being treated and use the term “active” history to describe a condition still requiring treatment and monitoring.

Now, in the example of ESRD—in most cases, if this is listed in the history and there are labs to support its presence, it can be coded. That is due to the fact that the patient with ESRD will continue to have some level of this disease (unless, of course, the patient receives a renal transplant etc.). If it’s unclear, query the provider. Most organizations have a list of diagnoses that can be coded even if they’re listed as a history. Conditions such as chronic obstructive pulmonary disease (COPD) do not improve and go away. So, if the provider stated “history of COPD,” I would not hesitate to code the diagnosis.

In general, though, my recommendation is that when you see this wording, proceed with caution and likely query if the status of the condition is not clear.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, and CDI education specialist at HCPro in Middleton, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps, visit www.hcprobootcamps.com/courses/10040/overview.