For Clinicians and Organizations
Time for another edition of my wildly popular “Success Codes” series. If you haven’t already, you may want to review my world class, yet humbly simple (yes, really) explanation of RAF scoring—it’ll help you understand some of the shorthand terminology below. It’s the only one on the web written by a PCP who’s been in the trenches blocking and tackling since Medicare Advantage first arrived on the scene 20+ years ago—and done so with incredible results.
That’s probably why it’s so good—and so good for you! Now let’s get started.
Chronic Kidney Disease is one of those areas of risk coding that seems overly technical and wordy, best left to others to extract.
Wrong tactic. Wrong strategy.
If you just passively rely on the data to make the diagnosis, you’ll miss a big opportunity to create systems that’ll promote the renal health of your patients for decades to come. And you’ll be putting yourself at risk for both clawbacks and missed revenue that can make or break your pool.
I screen my patients—as appropriate– for kidney damage with a random urine micro-albumin test. That means pretty much all my Medicare Advantage patients get screened.
If they screen in with detectable micro-albumin, I directly measure their Glomerular Filtration Rate (GFR) and protein loss through a 24 hour urine collection.
If there is indeed an impairment in renal function, I work them up as appropriate for possible etiologies, consider an ACE-I/ARB or other appropriate treatment and monitor their renal function more frequently based on what I find.
Note that early on, with a few exceptions, none of this will usually generate any additional revenue through higher capitation.
It’s simply good medicine.
But if I can slow the progression of the condition significantly—and the patient sticks with me for a long enough time—well, in that case the benefit to us both will be nigh incalculable.
There are 6 stages of Chronic Kidney Disease (CKD); 1-5 and Dialysis. In general, there must be two separate measurements of the GFR two months apart before a change in the stage of CKD can be documented. When in doubt, always use the higher stage, auditors will be looking for you to trip up.
Here goes;
- Stage 1 GFR >89 ICD-10 N18.1
Must have objective marker of renal damage such as micro-albuminuria..
RAF of 0.
- Stage 2 GFR 60-89 ICD-10 N18.2
Must have marker of damage, such as microalbuminuria.
RAF of 0.
- Stage 3 30-59 ICD-10 N18.3
No marker of damage needed.
RAF of 0.
- Stage 4 15-29 ICD-10 N18.4
No marker of damage needed.
RAF 0.2
- Stage 5 <15 ICD-10 N18.5
No marker of damaged needed.
Patient cannot be on dialysis.
RAF 0.2.
Besides the chronic level of renal impairment, be on the lookout for acute changes as well—but be careful!
- Acute kidney failure (ARF). N17.x RAF 0.5
Dreadfully over-diagnosed as an inpatient, where most “acute kidney injury” over diagnosed to ARF—a HUGE audit target.
Under-diagnosed in nursing homes and office setting—a HUGE potential miss.
As is common with most audit targets, it has a clear cut definition.
Learn the definition and apply it correctly.
- Dialysis
Don’t worry about capturing this code, the dialysis center has to submit it to get paid
But make absolutely sure you are evaluating and submitting their certain-to-be-present protein-calorie malnutrition and other co-morbidities—they won’t be.
Not doing so is a common miss—and one with huge implications for your patient and your personal performance
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