CKD documentation tips

 ICD-10-CM – Chronic Kidney Disease Documentation Tips

• Document the stage of CKD

–     Chronic kidney disease, stage 1
–     Chronic kidney disease, stage 2 (mild)
–     Chronic kidney disease, stage 3 (moderate)
–     Chronic kidney disease, stage 4 (severe)
–     Chronic kidney disease, stage 5
–     End-stage renal disease (ESRD)

• Document any underlying cause of CKD, such as diabetes or hypertension
• Specify if the patient is dependent on dialysis
• Note that “chronic renal failure” without a documented stage will be assigned to “chronic kidney disease, unspecified”
• Always document any associated diagnoses/conditions