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June 20, 2011

Treatment Options for Chronic Kidney Disease
For The Record
Vol. 23 No. 12 P. 28

When a person has healthy kidneys, these organs clean the blood by removing excess fluid, minerals, and wastes. However, when the kidneys fail, harmful waste builds up in the body, blood pressure may rise, and the body may retain excess fluid and fail to make enough red blood cells. When this occurs, treatment is needed to do the work of the failed kidneys.

Hemodialysis (ICD-9-CM code 39.95) is the most common treatment option for chronic kidney disease. It involves removing waste products and excess water from the vascular system, which balances the blood chemistry. Blood flows from the vascular access via a pump on the machine through a special filter (artificial kidney) that contains fibers. As blood moves across a filter membrane, the machine exerts negative pressure, removing excess fluid. Dialysis solutions travel in the opposite direction of blood, and waste molecules, such as creatinine and electrolytes, move across the gradient by osmosis, resulting in balanced blood chemistry.

Before hemodialysis can begin, a vascular access must be created weeks or months prior to the first treatment. A vascular access is the site on the body where the blood is removed and then returned during dialysis. Early preparation of the vascular access provides an efficient way for blood to be carried from the body dialyzer with little complications. Most of the time, the encounters for creating a vascular access will take place on an outpatient basis. There are three main types of vascular access: arteriovenous (AV) fistula, AV graft, and venous catheter.

An AV fistula (39.27), usually located in the forearm, is a surgically created connection between an artery and a vein. Increased blood flow makes the vein grow larger and stronger so it’s ready for repeated needle insertions. It may take weeks or months for an AV fistula to mature, but a well-formed fistula may last for years. Also, the chance of clots or infection is less likely.

An AV graft (39.27) connects an artery to a vein using a synthetic tube. The physician may choose this type of vascular access if the patient’s veins are small and may not properly develop the fistula. Although an AV graft may mature faster (two to three weeks after placement), this type of vascular access is more prone to developing clots or infection than an AV fistula.

A venous catheter is used for temporary access and is inserted into a vein in a patient’s neck, chest, or leg. It has two chambers to allow the two-way flow of blood. It is typically used for a few weeks or months while the permanent vascular access develops. However, the venous catheter may be used on a long-term basis if the AV fistula or the graft is unsuccessful.

The ICD-9-CM code assignment for a venous catheter depends on the type of catheter inserted. If it is a simple venous catheter for renal dialysis, assign code 38.95. However, if it is a totally implantable vascular access device (TIVAD), assign code 86.07. A TIVAD is implanted completely under the skin (at or below subcutaneous tissue).

In peritoneal dialysis, a fluid containing a special mixture of glucose and salts is infused into the abdominal cavity where it draws toxic substances from the tissues. The fluid is then drained out, discarded, and replaced with fresh fluid. This process uses the peritoneum in the patient’s body as a permeable filter. The catheter is inserted through the abdominal wall into the peritoneal space within the abdomen. The following are the main types of peritoneal dialysis:

• continuous ambulatory peritoneal dialysis (CAPD), where fluid is infused into the abdomen and remains there for several hours. It is typically drained and replenished four to five times per day. No machine is required.

• continuous cycler-assisted peritoneal dialysis (CCPD), which uses a machine called a cycler to fill and empty the abdomen three to five times during the night. Longer exchanges will be done without the cycler during the day. This may also be documented as automated peritoneal dialysis.

• a combination of CAPD and CCPD.

All types of peritoneal dialysis are classified to code 54.98.

Before a patient receives peritoneal dialysis, a special catheter must be inserted into the abdomen to carry dialysis solution into and out of the abdomen. Insertion of the peritoneal dialysis catheter is classified to code 54.93.

Another treatment is a kidney transplant, which is classified to code 55.69. If the patient’s diseased kidney is removed, then one of the following codes is assigned:

• 55.51, Nephroureterectomy (unilateral);

• 55.52, Nephrectomy of remaining or solitary kidney;

• 55.53, Removal of transplanted or rejected kidney; or

• 55.54, Bilateral nephrectomy.

In addition, the donor source should be identified with one of the following codes:

• 00.91, Transplant from live related donor;

• 00.92, Transplant from live nonrelated donor; or

• 00.93, Transplant from cadaver.

Coding and sequencing for treatment of chronic kidney disease are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.


ICD-10-PCS Coding for Treatment Options of Chronic Kidney Disease
When building a code in ICD-10-PCS, one of the most important aspects is to understand and correctly interpret the definitions of the root operations. If a coder picks the wrong root operation, then the wrong code will be assigned. The vascular access procedures will be located in the Medical and Surgical section. Creation of an arteriovenous fistula or the placement of a peritoneal dialysis catheter is classified as a bypass, or “altering the route of passage of the contents of a tubular body part.” The exact code assignment will depend on where the vascular access was created and which body part was involved.

Hemodialysis, single encounter, is classified to ICD-10-PCS code 5A1D00Z, which is located in the Extracorporeal Assistance and Performance section. Multiple encounters of hemodialysis is classified to code 5A1D60Z. Peritoneal dialysis is classified to code 3E1M39Z, which is located in the Administration section.

The index in ICD-10-PCS is helpful in directing the coder to the right table if the correct root operation is chosen. However, the coder must verify the code and properly select the other characters based on the procedure performed.

— Audrey Howard