Vol. 12 •Issue 5 • Page 12
Coding Tips for When Kidneys Fail
Chronic renal failure is a gradual deterioration of renal function that is rarely reversible. According to WebMD, it occurs in approximately two out of 10,000 people. Faye Brown’s Coding Handbook describes end stage renal disease as a “complex syndrome characterized by a variable and inconsistent group of biochemical and clinical changes that affect volume regulation, acid base balance, electrolyte balance, excretion of waste products and several endocrine functions. It is the progression of chronic renal failure to the point where regular dialysis sessions or a kidney transplant is required to maintain life.”
Patients with both a history of hypertension and renal failure are coded as 403.x1 because ICD-9-CM assumes a cause and effect relationship. If the patient also has hypertensive heart disease, a code from category 404.xx is used.
When diabetes is the underlying cause of chronic renal failure it should be coded as 250.4x followed by 585 or 403.91, if it is due to hypertension and diabetes. The physician must state a cause and effect relationship between diabetes and renal disease.
Patients with chronic renal failure are often admitted because of complications of the renal failure. Complications such as hyperkalemia, congestive heart failure and fluid overload are very common manifestations of chronic renal failure. Coding Clinic, second quarter 2001 states, “When a patient is admitted to the hospital with a diagnosis of hyperkalemia due to noncompliance with dialysis, the principal diagnosis should be 276.7 followed by the appropriate code for the renal failure. Also assign code V45.1 for renal dialysis status and code V15.81 for non-compliance with medical treatment. If the patient is admitted for treatment of congestive heart failure resulting from fluid overload, assign 428.0 as the principal diagnosis.”
The treatment of chronic renal failure focuses on controlling the symptoms and slowing the disease progression. Eventually, patients may require hemodialysis. Patients can be maintained on a regular schedule of dialysis for years. There are two types of dialysis: extracorporeal hemodialysis and peritoneal dialysis. Extracor-poreal hemodialysis substitutes for the functions of the kidneys by transporting blood outside the patient’s body for dialysis through an artificial kidney machine by a system of tubes connected to the patient’s circulatory system. Extracorporeal hemodialysis requires the insertion of a venous catheter (38.95), vascular access device (86.07) or creation of an AV fistula. Peritoneal dialysis uses the patient’s own peritoneum as the dialyzing membrane. Faye Brown’s Coding Handbook states, “When a patient is admitted for dialysis use code V56.0 as the principal diagnosis. Also code the procedure for extracorporeal hemodialysis (39.95) or code 54.98 for peritoneal dialysis.” “Patients are sometimes admitted for insertion of a catheter or vascular access device, but no dialysis is performed during the admission. The condition is then coded as the principal diagnosis. When dialysis is performed during the same episode of care, code V56.X is assigned as the principal diagnosis.”
When the kidneys fail, a normal kidney can be transplanted from a close relative or a recently deceased person. The transplanted kidney is placed in the iliac area outside the peritoneal cavity. Usually, the patient’s own non-functioning kidneys are not removed. Kidney transplant procedures are coded 55.69. A well-functioning kidney transplant can permit the patient to live a relatively normal life, however, complications can occur. Patients are placed on immunosuppressive drugs to prevent rejection of the transplanted kidney, leaving the patient susceptible to infection. If rejection occurs, assign code 996.81. Coding Clinic, third quarter 1998 states, “When a patient develops renal failure after a transplant, assign code 996.81 as the principal diagnosis followed by code 586 for the renal failure.”
Patients with chronic renal failure or end stage renal disease can develop complications of the treatment, including infections of the dialysis catheters. Patients may also develop anemia, congestive heart failure, pericarditis, hepatitis, electrolyte abnormalities, plus many more. It is important to carefully review the documentation in the medical record to determine the principal diagnosis. As always, the principal diagnosis is the “condition established after study that occasions the admission of the patient to the hospital.”
Sandy Stodgell is a senior consultant with HP3’s Coding and Audit Group.