Patricia Posted Tue 13th of July, 2010 23:04:55 PM
For the hospitalist Setting, in the H & P if the physician states the patient has a history of diabetes, hypertension, and chronic kidney disease, is it appropriate to code the diabetes with
403.90 and CKD
585.9. My major concern is using
250.40 for the diabetes. Is it safe to assume the CKD is a manifestation with the diabetes?
SuperCoder Answered Wed 14th of July, 2010 12:49:20 PM
Two scenarios are there:
1) Whether we can link Htn and CKD even if the word "hypertensive" is not present: Yes, you can assume a cause-n-effect" relationship b/w Htn & CKD. sO CODES COULD BE 403.90, 585.9
2) Whether DM can be taken as "linked with Htn & CKD": Actually, it depends on the documentation. If it's only history of diabetes, or current DM stated but not linked with the CKD somehow (like "diabetic CKD / CKD due to DM etc.), then you cannot code 250.40. That case, you should code as 250.00. To code 250.40, you should have some linked documentation.