Code Correctly for Hypertensive CKD

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Providers can justify billing for higher levels of service as patients' CKD, hypertension progress.


Recent changes in the diagnosis codes for hypertension will affect the billing for CKD patients.  Coding for patients with both hypertension and kidney disease presents unique problems. It is not enough to determine whether the patient has “benign,” “malignant” or unspecified hypertension or to question the stage of CKD. Coding when both conditions are present requires careful consideration by the coding professional.


Hypertension with heart disease re-quires that the provider state that there is a causal relationship (due to hypertension) or an implied relationship (hypertensive) to use series codes 402.XX. The coder then assigns a secondary code to define the type of heart disease that is present, such as congestive heart failure (428.0). In assigning code 402.--, the fourth digit “0” defines the type of hypertension as malignant, “1” as benign and “9” as unspecified. The fifth digit “0” defines the condition without heart failure and “1” is with heart disease.


But, in coding for hypertensive kidney disease 402.--, the guidelines change. There is a presumption that when hypertension and kidney disease are both present, there is a cause-and-effect relationship between the two conditions, and the diagnosis is coded as hypertensive kidney disease. As with hypertensive heart disease, the fourth digit is “0” for malignant, “1” for benign and “9” is for unspecified hypertension.


The fifth digit change from last year only defined the code as the patient having or not having kidney failure. The new 2007 guideline for the fifth digit “0” is with CKD stage I through IV or unspecified. The fifth digit “1” is defined as with CKD stage V or end-stage renal disease (ESRD). Then, a secondary code is required for each code to clearly define the stage of CKD present.


This change was made to be a “clinically significant indicator of the se-verity and resource intensity the patient's disease requires to manage” (as noted in 2007 ICD-9-CM Changes: An Insider's View by Ingenix). By coding the hypertensive kidney disease correctly, the provider can justify billing for higher levels of service as the patient's renal disease and hypertension progress.


Since it is clinically more difficult to care for a hypertensive renal disease patient at stage IV CKD than at stage II CKD, billing for higher levels of service is justified. Remember, it is the level of service, not the diagnosis, for which we bill.


Similarly, 585.6 ESRD is also clarified as “chronic kidney disease requiring chronic dialysis.” This will allow for more comprehensive definition between stage V and stage VI, which both define the glomerular filtration rate value as less than 15.


By understanding the presumed relationship between hypertension and CKD, the provider and coder can more accurately code the patient's condition, which will ultimately support the level of service provided by the physician. Such correct coding will result in more equitable and appropriate reimbursement.


For more information about ICD-9 diagnosis codes, please refer to Renal Physicians Association's Nephrology ICD-9 Reference Codes brochure, which is available by contacting RPA at (301) 468-3515 or or online at


Debra Lawson is a certified professional coder and the former director of reimbursement for Nephrology Associates of Tidewater in Norfolk, Va. Ms. Lawson is a contributor to

RPA's publication The Renal Physician Guide to Nephrology Practice. She also conducts the RPA nephrology coding and billing seminars.


Editor's Note: RPA consciously takes a conservative position when providing coding and billing advice to its members, since the possible unintended consequence of taking a less conservative approach could be a claims audit with the potential of doing tremendous harm to an RPA member's practice. Similar to the FAQ page on the RPA website, this column has been designed as a general information re-source. It is not intended to replace legal advice.


This information was provided by the Renal Physicians Association (, which has partnered with Renal & Urology News to create our new column. This installment is based on material that appeared first in RPA's newsletter, RPA News.

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