E/M Hot Topic: Social Determinants of Health
With the use of the 2021 E/M Guidelines, questions continue to surface. In this month’s E/M Hot Topic, Director of Education, Jeanie Heck, BBA, CCS, CPC, CRC discusses Social Determinants of Health. She also provides an update to Prescription Drug Management and the Ordering/Review of Tests.
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The ICD-10-CM code for Chronic Kidney Disease (CKD) Stage 3 (N18.3) has been revised for Fiscal Year 2021. The most recent update to the CMS-HCC Risk Adjustment Model has CKD Stage 3 making an impact on Risk Adjustment Factor scores. On the other hand, CKD Stage 3 is not recognized as a complication or comorbidity (CC) in the DRG world of coding.
Not only do the new codes for CKD Stage 3 give more specificity and capture more detail, but they also help to define more precisely the edge within Stage 3 at which mortality becomes the main concern.
The new codes are as follows:
- N18.30 CKD, Stage 3 unspecified
- N18.31 CKD, Stage 3a (GFR = 45-59)
- N18.32 CKD, Stage 3b (GFR= 30-44)
Kidney disease is often asymptomatic and occurs just before kidney failure. About one-third of the population of older adults have CKD Stage 3. When someone is experiencing Stage 3, it means their kidneys are filtering about half of what they should be, allowing for some fluids, electrolytes, and waste to build up in the body.
CKD often starts to develop without notice. However, symptoms may appear in Stage 3. For those that do experience symptoms, these may include fatigue, swelling around the ankles or eyes, unusually light-colored urine, urinating more frequently, and loss of appetite.
Once an individual has Stage 3 CKD, it’s generally considered to be irreversible. Fortunately, the majority of Stage 3 patients do not progress to the more severe stages. Still, it is important to work with a doctor to manage the condition and gain a clear picture in regard to the GFR and kidneys. This helps to identify the need for kidney replacement therapy sooner and essentially helps to keep the patient healthier longer.
“1 in 2 people with very low kidney function who are not on dialysis do not know they have CKD (chronic kidney disease).” — Center for Disease Control
The implications of untreated or unmanaged kidney disease can be life-altering or lethal. CKD is a manageable co-morbid condition in its early stages with the potential for reversibility, however, once chronic kidney disease hits the later stages, management of the disease becomes significantly more resource consumptive. CMS is now in line with the clinical information by updating the most recent version of their HCC’s to reflect that even moderate CKD impacts the patient’s risk.
The intention of hierarchical condition category (HCC) coding is to utilize the patient’s medical conditions, demographics, and interactions of the patient’s diseases to calculate a risk adjustment factor (RAF) score. The RAF score conveys the severity of the patient’s conditions in a calendar year in an attempt to reflect the level of resource consumption required to manage the patient. Anyone assigning diagnosis codes, regardless of setting, should be aware and educated on this risk-based payment methodology.
Inpatient care, awareness of kidney function matters for the management of other disease processes and medications. In coding, the accuracy of appropriate staging does not just impact the care rendered. Accuracy also ensures that the patient’s RAF score accurately reflects the resource consumption of their disease process. Through code assignment and documentation, the diagnosis can be linked to those underlying conditions that most often cause degradation of the kidneys- hypertension, and diabetes.
In earlier versions of CMS-HCCs, CKD did not carry significant risk (as demonstrated through weight) until the patient’s disease had reached stages 4, 5, or end-stage renal disease. In this case, the eGFR (estimated glomerular filtration rate) has typically dropped below 30, demonstrating a serious impact on the ability to clear waste products from the bloodstream.
CKD stage 3 (eGFR typically ranging 30-59) was not recognized as a hierarchical condition category code. This changed, however, with the introduction of CMS-HCC version 24. Why the change? CKD stage 3 (N18.30) has clinically significant ramifications for comorbid disease management and medication usage. Treating and managing a patient with CKD stage 3 before progression to later stages has a significant impact on the health of the patient. CMS did not outright make this statement but it’s a clinically logical deduction from the understanding of CKD disease progression.
In the inpatient setting, CKD stage 3 is not recognized as a complication or comorbidity (CC) so clinical documentation specialists may be overlooking this important risk adjusting condition. It is important that whether functioning in the inpatient or outpatient setting, CDI specialists and coders focus on getting accurate information reflecting the patient’s health status documented in the medical record. Take a deep look at the details of the patient encounter next time “CKD, unspecified” (N18.9) appears in the record.
Wondering about those more specific CKD stage 3 codes? Look for more information regarding CKD stages 3a and 3b in future tips!
Now that we have been applying the new 2021 E/M guidelines for over a month, there’s no doubt that we have questions about some of the changes — especially the elements in MDM! Starting Feb 9th, Jeanie Heck, our Director of Education, will begin addressing “E/M Hot Topics” in monthly 10-20 minute presentations.
For additional information about E/M Updates education, contact us.