Question:

When DM is an affecting condition for URI and the patient also has CKD, which is not treated or affecting at this encounter, do I use the combination code for hypertensive CKD or just the DM code?

Answer:

ICD-10-CM General Coding Guidelines state the following: “The classification presumes a causal relationship between two conditions linked be these terms (with or in) in the Alphabetical Index or Tabular List. The conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless documentation clearly states the conditions are unrelated.”

If the provider documentation states the patient has URI, DM and CKD, the correct coding should be J06.9, E11.22, N18.- (code the stage of CKD N18.1 – N18.6). The scenario does not mention that the patient has hypertension; therefore, hypertensive CKD would not be an appropriate code. However, if the provider’s documentation does state the patient also has hypertension, an additional code of I12. (The fourth character is dependent upon the stage of the CKD.)

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