Provider Blog / Recapturing CKD
May 8, 2025
Recapturing Chronic Kidney Disease (CKD)
Through record reviews, the Risk Adjustment team has noticed that we are missing the ability to recapture 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, as it allows a clearer picture of the patient’s overall health. It also helps all providers treating the patient to allow for a 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. This is where monitoring, evaluation, assessment, and/or treatment (MEAT) comes into play, for this to be an exact picture of the patient’s health. The condition needs to show it is currently being monitored, evaluated, assessed, and treated. This can be shown through lab values, treatment plan, medications, and patient education during the visit. Accurate coding is crucial to give a true visual of the patient.
Simply saying the patient has CKD stage 3 in History and Physical is not acceptable without supporting evidence (i.e., documented labs, noted treatment plan). Think of your documentation as the following: A patient note is the primary communication tool to other clinicians treating the patient, as well as a statement of the quality of care.
Here is an example of being able to capture CKD. The following appeared in a chart that was documented as follows 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
Nicely done!
What is Hierarchical Condition Category (HCC) Recapture?
HCC recapture involves revalidating and documenting chronic conditions for each patient at least annually.
Why it’s important to HCC recapture:
- Improved patient care
- Accurate risk adjustment
- Compliance and audits: Proper documentation of MEAT 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, however, if you are aware a particular patient tends to seek appointments only when either ill or requiring a refill, that is the best time to capture chronic conditions for them and provide education as well.
Documentation Requirements for Chronic Conditions
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.