Chronic Kidney Disease (CKD) Documentation Guide
Progressive loss of kidney function over months to years, classified by GFR stage and albuminuria category.
ICD-10 Codes: N18.1, N18.2, N18.3, N18.30, N18.31, N18.32, N18.4, N18.5, N18.6, N18.9
Common Symptoms
- Often asymptomatic in early stages
- Fatigue
- Edema
- Nausea
- Decreased urine output
Key Documentation Elements
- CKD stage (1-5) based on eGFR
- Albuminuria category (A1, A2, A3)
- Underlying etiology (diabetes, hypertension, etc.)
- Current eGFR and trend
- Nephrotoxic medication review and adjustments
Documentation Challenges
- Staging CKD accurately by GFR and albuminuria
- Documenting underlying etiology and contributing factors
- Recording medication dose adjustments for renal function
- Tracking progression and nephrology referral criteria
Billing Considerations
- Stage-specific coding (N18.1 through N18.6)
- HCC implications for CKD stage 4-5
- Chronic care management billing for ongoing CKD
Frequently Asked Questions
What ICD-10 codes are used for CKD staging?
CKD is coded by stage: N18.1 (stage 1), N18.2 (stage 2), N18.30-N18.32 (stage 3), N18.4 (stage 4), N18.5 (stage 5), N18.6 (ESRD). Scribeable selects the correct stage based on your documented eGFR values.
How does Scribeable help with CKD documentation?
Scribeable captures eGFR values, albuminuria status, medication adjustments, and etiology discussions from your encounter, ensuring accurate staging and complete documentation for chronic kidney disease management.