Coding Guide from CMS (with examples)

The following is a document CMS has shared regarding their findings on a Calendar Year 2024 Medicare part C Improper payment Measure, reviewing END-stage Renal Disease (ESRD), CKD, CVA, Sepsis, Pneumonia, CAD and MI. 

While it is too late to correct CY 2024, please use this as a reference tool moving forward. You might choose to make several copies for the office to have easily accessible in areas of documentation and coding. 

You may even what to have a brief meeting to review the information with all staff who actively have a role in documenting or coding medical records. It is rare for CMS to share these findings like this! 

Please use the following document as a reference guide when coding. 

Below you will find a list that CMS has sent out regarding supporting documentation for End-Stage Renal Disease (ESRD) Enrollee Hierarchical Condition Category (HCC) Supporting Documentation Guide for calendar year 2024 (CY2024). 

Note: This guide does not include all possible scenarios. Submitting a record based on the information included in this guide does not guarantee a valid submission; the Centers for Medicare & Medicaid Services’ (CMS’) medical record reviewers must review the entire record to determine validity. Chronic Kidney Disease (CKD) Documentation Issues Table 1 lists the common reasons CKD HCCs are not found, along with examples of the documentation issues that lead to a discrepant HCC. This information is not all-inclusive of possible scenarios. 

While you cannot go back in time and change records, this is being offered as valuable information moving forward in documentation for 2026 and beyond for medical record documentation. 

Please review and move forward to make the necessary adjustment to documentation of this condition. 

REASON HCC NOT FOUND	COMMON DOCUMENTATION ISSUE
CODING ERRORS
Stage is not specified or different stage documented    Stage is not specified or different stage documented con’t	Only a different stage of CKD is documented rather than the audited HCC  A past stage is documented, but the current stage is different  CKD is documented, but no stage is documented
Diagnosis is ruled out	CKD has been ruled out in the record
Diagnosis not further specified	Kidney disease is documented but there is no mention of it being “chronic”; cannot confirm it as being CKD
Numeric code without narrative, or incorrect numeric code next to narrative    Only the narrative can be used for coding	An incorrect numeric code was written next to a narrative that resulted in a different code   Only a numeric code was documented with no documentation of a written narrative
Uncertain diagnosis (on outpatient submission or in inpatient record but not at discharge; therefore, unable to confirm)	CKD is only documented as uncertain (possible, questionable, likely, etc.) on an outpatient record and is not confirmed anywhere  CKD is only documented as uncertain in an inpatient record, and it is not documented on the day of discharge
History of, not current condition	History of, not current condition
Condition eradicated status-post surgery	The patient had CKD in the past but has had kidney transplant, and there is no current CKD documented
Invalid documentation in valid medical record (MR)	CKD was only found on invalid documentation, such as a Problem List with a future date, a diagnostic report, by an invalid provider (nurse, dietician, etc.), on a different date of service, or on another invalid source

DOCUMENTATION SCENARIO	ASSIGN
Inpatient record: The past medical history in the H&P documents CKD stage 3 but the Assessment documents CKD stage 2. There are no other current stages documented in the record.	CKD stage 2, N182 (not HCC)  Take the current stage during the hospitalization rather than the past stage.
Outpatient record documents CKD stage 4 in Past Medical History. There is no current stage documented anywhere in the record.	CKD stage 4, N184 (HCC 137/327*)  There is no current stage, so the past stage may be assigned.
Outpatient record documents CKD stage 2 in the Past Medical Record History and CKD stage 3 in the Assessment.	CKD stage 3 (unspecified), N1830 (HCC 138/139*)  Take the current stage in the assessment.
Outpatient record Final Assessment documents both CKD stage 3a and CKD stage 4.	CKD stage 4, N184 (HCC 137/327*)  Take the highest stage from the current Assessment.
Inpatient record History & Physical documents a current stage of CKD 5. The Discharge Summary documents a current stage of CKD 4.	CKD stage 5, N185 (HCC 136/326*)  Assign the highest stage during the current inpatient stay.
Outpatient record documents Moderate CKD in the Assessment.	CKD stage 3 (unspecified), N1830 (HCC 138/329*)  Per the ICD-10-CM Official Guidelines for Coding and Reporting, “Moderate” equates to stage 3.
Observation record documents CKD stage 4 at admission and CKD stage 3a at discharge.	CKD stage 4, N184 (HCC137/327*)  Both stages are during the current observation hospitalization, so assign the highest stage.
Inpatient record documents CKD stage 5 and ESRD during the current hospitalization.	ESRD, N186 (HCC 136/326*)  Per the ICD-10-CM Official Guidelines for Coding and Reporting, when both a stage of CKD and ESRD are documented during the stay, assign only the ESRD.
A standalone Hospitalist progress note from an inpatient stay is submitted as an outpatient record. In the Hospital Course, the provider says that the patient had presented it to the Emergency Room with CKD stage 4. The Assessment documents CKD stage 3b.	CKD stage 4, N184 (HCC 137/327*)  The highest stage during the current hospitalization should be assigned.
A standalone Hospitalist progress note from an inpatient stay is submitted as an outpatient record. The Past Medical History documents CKD stage 4. The Assessment documents CKD stage 3b.	CKD stage 3b, N1832 (HCC 138/328*)  The stage during the current hospitalization is CKD stage 3b. CKD stage 4 is a past stage.
In a Physician office note, the Assessment documents CKD stage 2, as well as Hypertensive CKD stage 1 through stage 4 CKD or unspecified CKD.	CKD stage 2, N182 (No HCC)  Assign the specified stage of CKD 2. The narrative for hypertensive CKD does not document a specific stage.
The Past Medical History states CKD stage 5. The patient is status-post kidney transplant. No current CKD is documented.	CKD is a history and was eradicated with the transplant and should not be assigned.

* The two values shown indicate the HCC model versions (ESRD V24/V28). The first number corresponds to the ESRD 24 model, and the second number corresponds to the V28 model HCC. 

Acute Condition Documentation Issues

Acute conditions are illnesses that generally develop suddenly and last a short time, often only a few days or weeks. These conditions can impact patients with CKD. Please keep the following information in mind when selecting documentation to support acute conditions:  

• Do not code acute conditions from record areas such as Problem Lists or Past Medical History, unless there is current treatment.  
• A myocardial infarction (MI) is only acute during specific timeframes (during the initial acute care stay and within four weeks of the initial acute care stay). If the MI occurred more than four weeks prior, then “Old MI” should be assigned.  
• A cerebrovascular accident (CVA)/stroke is only acute during the initial episode of care. An acute stroke happens suddenly and needs immediate medical treatment to reduce brain damage. Any neurological deficits are assigned as Sequela and not as an acute stroke. If there are no deficits, a history of CVA should be assigned. During the acute care of an acute CVA (Emergency Room/inpatient admission), the acute cerebral infarction codes may be assigned (I63.-). After the acute care stay, it is no longer an acute CVA. Any neurological deficits that are still present should be assigned (I69.-). If there are no deficits, the personal history code should be assigned (Z8673). If a patient transfers to rehab after an acute care stay for an acute CVA, it is no longer an acute CVA. Assign any current deficits or a history of a CVA. 

DOCUMENTATION SCENARIO	ASSIGN
CVA is documented in an outpatient record. It is a routine exam and there is no emergency transfer to an Emergency Room. There are no neurological deficits.	Assign Z8673, Personal history of CVA without residual deficits (No HCC). This is not an acute CVA.
The patient presented to the Emergency Room with left hemiparesis and slurred speech. A computed tomography (CT) scan of the brain confirmed an ischemic stroke. The patient was admitted and treated with intravenous (IV) medication. The Discharge Diagnosis included “Left hemiparesis due to CVA.”	Assign I639, Cerebral infarction unspecified (HCC 100/249*), G8194, Hemiplegia, unspecified affecting left nondominant side (HCC 103/253*), and R4781, Slurred speech (No HCC). This is an acute CVA for which the patient was treated during the current hospitalization.
The History of Present Illness documents a history of malnutrition. The patient is not on any nutritional supplements or treatment. Malnutrition is not mentioned elsewhere.	Do not assign a code for malnutrition.   It was only in the past, and there is no current treatment.
An outpatient patient follow-up visit after hospitalization documents sepsis in the Chief Complaint, and the patient is finishing up on antibiotics. The Assessment documents “resolving sepsis,” and the patient also had pneumonia in the hospital (no specific type of pneumonia documented).	Do not assign a code for sepsis. This is an acute condition, which is treated in a hospital until resolved. Assign J189, Pneumonia, unspecified organism (No HCC).
An outpatient office visit documents acute kidney injury (AKI) in the Problem List. The patient was hospitalized a month ago. There is no other mention of AKI.	Do not assign a code for AKI. It is a past acute condition that was treated in the past.
The Past Medical History documents coronary artery disease (CAD) with angina. The current medication list does not include nitrates or any medication that could treat angina.	Assign CAD without angina, I2510 (No HCC). The angina is only in the past history, and there is no current treatment.
The Past Medical History documents CAD with angina. The current medication list includes nitroglycerine.	Assign I25119, CAD with unspecified angina (HCC 88/-). Nitroglycerine is a current treatment for angina.
The patient presents to the Emergency Room for shortness of breath on April 27. The Past Medical History shows that the patient had an MI on February 18.	Assign I252, Old MI (No HCC). The MI was more than four weeks ago. Do not assign an acute MI.

* The two values shown indicate the HCC model versions (ESRD V24/V28). The first number corresponds to the ESRD V24 model HCC, and the second number corresponds to the V28 model HCC.