What do you do if a patient had met the criteria for ESRD, but is waiting for dialysis access to be established, and sufficient healing time to decrease the risk of leak/infection? We have had coders stubbornly refuse to let us even query the physician for the diagnosis, stating that the patient doesn’t meet ESRD diagnosis standards because they are not yet being dialyzed.
Knowing that CMS defines ESRD as "a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life." you can, of course, pluck out your hair. (Some of our veteran physicians are getting quite bald from such frustrations.) You might, however, ask them to consider the following Coding Clinics:
ICD-10-CM/PCS Coding Clinic, Fourth Quarter 2013 Page: 125 Effective with discharges: October 21, 2013 Question: The patient is a 41-year-old female with a history of lupus complicated by lupus nephritis and CKD stage 5, which has progressed to end stage renal disease (ESRD). She is admitted for insertion of a peritoneal dialysis catheter that was placed without complications. She was discharged with plans to follow-up with a dialysis nurse as an outpatient and to start peritoneal dialysis once the site has healed. Given the circumstances of admission, which condition should be sequenced as principal diagnosis (ESRD or the lupus nephritis)? The patient is not currently on dialysis.
Answer: Sequence code N18.6, End stage renal disease, as the principal diagnosis. In this case, treatment is being directed at the ESRD. Although lupus is a contributing problem, it is not the focus of treatment. Assign code M32.14, Glomerular disease in systemic lupus erythematosus, as an additional diagnosis. Code Z99.2, Dependence on renal dialysis, is not appropriate since the patient has not yet started dialysis.
ICD-10-CM/PCS Coding Clinic,Second Quarter 2013 Page: 5 Effective with discharges: July 8, 2013
Question: What is the code assignment for end stage renal disease (ESRD) that is documented as "approaching hemodialysis" and "not yet on dialysis?"
Answer: Assign code 585.6, End stage renal disease, for ERSD if the provider documents it as such. "Chronic kidney disease requiring chronic dialysis" is an inclusion term for which code 585.6 may also be assigned, however the note does not affect the code assignment for end stage renal disease. The inclusion term simply means that chronic kidney disease requiring chronic dialysis is assigned code 585.6 even when the condition is not specifically documented as end stage renal disease.