ICD-10 essentials for busy physicians who would rather be doing something else – Urology and Nephrology

I swear, I chose the three conditions I thought would best meet the 80/20 rule for urologists or nephrologists and the physicians whose patients end up seeing these specialists: treatment of urinary stones, an enlarged prostate, or management of chronic kidney disease.

And then I discovered that coding and documentation for these three conditions is the embodiment of “no big deal,” the kind of thing I have been saying all along. Or to put it a bit more Old World, here is a Catalan blessing from Stephen Maturin, my favorite (fictional) physician: May no new thing arise. There are practically no changes here. Enjoy.

Urinary calculus
If you think this is some kind of new math, you have landed on the wrong blog. It’s not. Urinary calculus describes those tiny, spiky, evil little caltrops of calcium that cause unbearable pain when they grow large enough to get stuck somewhere, like the ureter. The ICD-10 codes that classify calculus in the urinary system are nearly untouched. Something like “don’t mess with a good thing” is at work here. In describing stones in the urinary system, the detail is in the anatomic site, and site is the focus of the ICD codes in both version 9 and version 10.

The only real changes are the addition of two new codes. N20.2 Calculus of kidney with calculus of ureter can be used -- logically enough -- when the patient has stones in both places. N22 Calculus of urinary tract in diseases classified elsewhere can be used when some underlying condition like inflammatory bowel disease or gout is known to be causing the patient to develop urinary stones. The other codes are unchanged between ICD-9 and ICD-10, and when I say unchanged I mean unchanged -- not a letter, not a comma out of place, only the code itself is different. Below are a few examples.

N20.0 Calculus of kidney  


592.0 Calculus of kidney

N20.1 Calculus of ureter  


592.1 Calculus of ureter

N21.1 Calculus in urethra 


594.2 Calculus in urethra 

Enlarged prostate
There are actually fewer codes in ICD-10 for benign enlarged prostate. This is because in ICD-9 codes classified benign enlargement of prostate based on whether the type was hypertrophy or benign localized hyperplasia, morphological distinctions that are usually the province of pathologists. These distinctions were retired in ICD-10 and the codes simplified. Enough said — I’ll let the codes speak for themselves.

N40.0 Enlarged prostate without lower urinary tract symptoms  


600.00 Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) 

600.20 Benign localized hyperplasia of prostate without urinary obstruction and other lower urinary tract symptoms (LUTS) 

600.90 Hyperplasia of prostate, unspecified, without urinary obstruction and other lower urinary symptoms (LUTS)

N40.1 Enlarged prostate with lower urinary tract symptoms  


600.01 Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) 

600.21 Benign localized hyperplasia of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) 

600.91 Hyperplasia of prostate, unspecified, with urinary obstruction and other lower urinary symptoms (LUTS) 

Chronic kidney disease
The addition of new codes for staging CKD in ICD-9 was borrowed from ICD-10, so the two code sets are now in sync, the only difference being that ICD-9 chose for whatever reason to use Roman numerals in the description. Stage 4 example appears below.

N18.4 Chronic kidney disease, stage 4 (severe)  


585.4 Chronic kidney disease, Stage IV (severe)

The improvement in ICD-10 is that companion codes for the underlying cause of the CKD are nicely correlated with the CKD codes in the book, so coding CKD and its cause is a snap.

For example, right under the CKD codes the instructions in the ICD-10 book tell you to code first any associated diabetic chronic kidney disease, and then give you the five precise code options (for the five “types” of diabetes type 1, type 2, two subtypes of secondary diabetes, and “other specified”): E08.22, E09.22, E10.22, E11.22, E13.22. The type 1 and type 2 codes are shown below with their descriptions.

E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease 


250.41 Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled 

E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease  


250.40 Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled

Compare them with the ICD-9 “information” they replace. They actually say diabetic chronic kidney disease in the description, whereas the old ICD-9 code says nothing of the kind. Since these new codes are unambiguously the correct ones for a patient with CKD due to diabetes, the only choice you need to document for is the type of diabetes in order to pick the best code.

As long as I am trotting out folk sayings, here is an old Chinese curse that could be used in connection with healthcare reform and ICD-10 politics: May you live in interesting times. Next blog I’ll try to come up with something a bit more interesting for you.

Rhonda Butler is a senior clinical research analyst with 3M Health Information Systems. She is responsible for the development and maintenance of the ICD-10 Procedure Coding System since 2003 under contract to CMS, and for the development and maintenance of the ICD-10 General Equivalence Mappings (GEMs) and Reimbursement Mappings under contract to CMS and the CDC.  She leads the 3M test project to convert the MS-DRGs to ICD-10 for CMS, and is on the team to convert 3M APR-DRGs to ICD-10. Rhonda also writes for the 3M Health Information Systems blog.


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