I am reviewing a case where the principal diagnosis will be Acute Exacerbation of Diastolic CHF with Hypertension (I11.0). There was documentation of an elevated BUN and Creatinine with “probable stage 2 renal insufficiency.” The renal insufficiency was not specified as “chronic”. Based on this documentation, would it be appropriate to change the principal diagnosis to Hypertensive Heart and Chronic Kidney Disease (CKD) with Heart Failure and CKD, Stages 1-4 (I13.0)?
Query the physician to clarify the renal insufficiency, because the documentation did not specify the renal insufficiency to be “chronic.” In addition, there is no entry in the code book/encoder for stage 2 renal insufficiency that will give the code for Stage 2 CKD. Assigning a code that is not specifically documented in the record may be viewed as up-coding.
Coding Clinic, 2nd Quarter 2000, pages 17-18
FY 2019 Inpatient Coding Guidelines