Health data standards and systems

Scenario 1: Patient admitted for treatment of chronic active kidney transplant rejection with IV methylprednisolone.

Scenario 2: Patient admitted for biopsy of transplanted kidney for ? rejection with diagnosis of chronic rejection on histology.

According to the new Index entry in Ninth Edition below, we should code these to chronic kidney disease, however this doesn't seem appropriate when the admission is for treatment or investigation of the rejection, not the CKD.

Failure, failed
- transplant T86.9
- - kidney
- - - acute T86.1
- - - chronic (irreversible) - see Disease/kidney/chronic

It seems that this index entry was added due to the Coding Rule below, however it seems like there should be more options in the index. Can you please confirm that the index entry to code CKD should be followed in these scenarios?

Ref No: TN197 | Published On: 15-Mar-2010 | Status: Current
Kidney transplant failure/kidney transplant status
Q:
A patient admitted to hospital is noted to have had a previous renal transplant which had failed and the patient was now requiring dialysis. Should kidney transplant failure be assigned or kidney transplant status?
A:
Hyperacute rejections of transplanted kidneys are immediate and acute rejection is highest in the first three months after transplantation. However, acute rejection can also occur months to years after transplantation. Chronic transplant rejection is irreversible and cannot be treated effectively. When deciding whether to code kidney transplant failure or kidney transplant status the coder should attempt to determine, from the information in the clinical record, whether the failed transplant is chronic and irreversible or in an acute rejection phase. Acute rejections will likely be the focus of the admission with the objective being the treatment of the rejection. For chronic irreversible kidney transplant rejection, the patient is likely to be on maintenance dialysis to treat the CKD stage 5. Therefore, T86.1 Kidney transplant failure and rejection should only be assigned for acute kidney transplant rejections that meet the criteria for code assignment as per ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses. Z94.0 Kidney transplant status should be assigned as per the following advice in ACS 1438 Chronic kidney disease, Kidney replacement therapy which states:
"For patients who have received a kidney transplant and documentation pertaining to this status satisfies criteria for coding under ACS 0002, assign Z94.0 Kidney transplant status together with N18.3 Chronic kidney disease, stage 3 or higher, as indicated by an eGFR level." Therefore, for a patient with a failed kidney transplant who is now requiring dialysis, as per the scenario cited, assign Z94.0 Kidney transplant status in addition to N18.5 Chronic kidney disease, stage 5. If it is impossible to determine whether the transplant rejection is acute or chronic, then the coder should seek clarification from the clinician.
(Coding Matters March 2010 Volume 16, Number 4).

VICC advises that it is correct to follow the Index entry Failure/transplant/kidney/chronic - see disease/kidney/chronic for the scenarios cited in the query as both scenarios have chronic transplant rejection documented. Although the code title at T86.1 is Kidney transplant failure and rejection, the Index only allows this code to be assigned for acute kidney transplant rejection.

Therefore only assign CKI stage 3 or higher with the addition of kidney transplant status code as per ACS 1438 Chronic Kidney Disease.

You may wish to write a public submission to ACCD suggesting the Index entries be reviewed.