Coding Tip Corner – May 2026

Recapturing Chronic Kidney Disease

When recapturing chronic kidney disease (CKD) stages 3-5, specificity matters! Unspecified CKD (N18.9) and unspecified kidney failure (N19) do not risk adjust. Correct coding is crucial because it paints a clearer picture of the patient’s overall health. It also allows all providers treating the patient to create a more consistent treatment plan based on the patient’s chronic conditions.

CKD stages 3-5 noted in history and physical without supporting documentation does not allow for the capture of the stage of CKD. The condition needs to show it is currently being monitored, evaluated, assessed, and treated (MEAT). This can be shown through lab values, treatment plan, medications, and patient education during the visit.

Simply saying the patient has CKD stage 3 in the history and physical is not enough without supporting evidence, i.e., documented labs and noted treatment plan. Remember, a patient note is the primary communication tool to other clinicians treating the patient, as well as a statement of the quality of care.

Example: Appropriate Documentation for CKD

Here’s an example of CKD documented under a Medicare Annual Wellness visit and follow up: 

• • Assessment T2 IDDM with CKD2 and HTN 
  • CKD stage 2 due to type 2 diabetes mellitus 
  • Discussed how and what you eat and drink can aid in kidney protection: 
    • Stay well hydrated 
    • Avoid high salt foods 
    • Avoid NSAIDS 
    • Keep BP and BG well controlled 
    • Take medications as prescribed 
    • Remain active and exercise as tolerated daily 
    • Maintain weight 
    • Continue to monitor 
    • Check CMP/GFR/Microalbumin

Hierarchical Condition Category (HCC) Recapture

HCC recapture involves revalidating and documenting chronic conditions for each patient at least annually. HCC recapture is so important because it leads to: 

• • Improved patient care
  • Accurate risk adjustment
  • Proper documentation of current monitoring, evaluation, assessment, and/or treatment (MEAT), which mitigates the risk of penalties associated with coding errors or underreporting

Capturing a chronic condition can be done anytime the patient has an appointment. An annual visit is the ideal time to recapture all chronic conditions, but if a particular patient tends to seek appointments only when ill or requiring a refill, that is the best time to capture chronic conditions and provide education.

Accurate and detailed documentation is crucial for proper billing and reimbursement for chronic conditions. Here are some key documentation tips:

• • Chronic Condition Status: Clearly document the chronic condition and whether it is stable, controlled, or exacerbated.
  • Comorbidities and Complications: If applicable, document any comorbidities or complications related to the chronic condition (e.g., diabetic nephropathy, congestive heart failure).
  • Treatment Plan: Include information on prescribed medications, therapeutic interventions, lifestyle changes, and any referrals or specialist consultations.
  • Follow-up and Monitoring: Provide evidence of regular monitoring, such as lab results, imaging, and vital signs, especially for conditions like diabetes or hypertension.

Keeping medical documentation current gives the practice a complete picture of the patient’s health. This enables more efficient, effective, and targeted patient care.