RMC’s AHIMA Approved ICD-10 Trainers meet multiple times per week fielding questions from clients and staff.  Below is an actual question that was submitted, along with our team’s response.*

Coding Question: 

I am in need of some clarification regarding coding of CKD/DM/HTN.
Documentation is for DM with renal manifestation. Patient w/  CKD and HTN.
Guidelines instruct a presumed relationship between CKD and HTN unless due to other cause……

Since both DM and HTN are both presumed causes of CKD does the physician have to specifically state that the CKD is NOT related to the HTN……. Or does the documentation of DM with renal manifestation imply that there is no linkage between the CKD and HTN.


RMC Answer: 

Yes! The provider must state that the CKD is NOT related to the HTN.

Let us know your thoughts! We want YOU to join the conversation! Submit YOUR questions at codingquestions@rmcinc.org

* Every effort has been made to answer these questions to the best of RMC’s abilities, at the time the original question was submitted.  Answers should not be considered official coding advice, and we always encourage conversation and dialogue regarding our responses.  As best practice policy, always be sure to refer to your Official Coding Guidelines , Coding Clinic, CPT Assistant, etc.