Blog Post

Risk Adjustment and CKD: Capturing Co-Morbidities


Appropriate coding and documentation are key components to succeeding in Value-based Care models.

The Center for Medicare and Medicaid Services (CMS) uses Hierarchical Condition Categories (HCC) in conjunction with patient demographics to generate a risk score for each patient that helps to predict their expected health expenditures. The greater the burden of an individual’s illness, the higher their risk score. CMS then adjusts payments to Medicare Advantage plans and a variety of Alternative Payment Models based on their population’s calculated risk. Accurate and appropriate coding and documentation is critical to help secure sufficient resources to care for your patient’s needs.

Chronic Kidney Disease (CKD) patients carry a high disease burden. It’s not unusual for CKD patients to have a variety of co-morbidities like obesity, diabetes, hypertension, peripheral artery disease, sleep apnea and other medical problems. The challenge for providers is to code to the highest degree of specificity and capture accurate supporting documentation for each code used. For example, there are multiple codes used to capture CKD stages. Here are three codes used to capture Stage 3 CKD:

  • N18.30 CKD, Stage 3 unspecified
  • N18.31 CKD, Stage 3a (GFR = 45-59)
  • N18.32 CKD, Stage 3b (GFR= 30-44)
Unspecified codes should be avoided when possible as there is always a more specific option. In this case, a provider can code to a higher degree of specificity if a patient’s GFR is documented.

Many patients with CKD also suffer from diabetes, which can in turn be accompanied by such complications as neuropathy, retinopathy, and circulatory complications. Each of these conditions will have its own unique HCC diagnosis code.

Providers have a lot on their plate. They are trained to take care of patients, not to be coding experts, which can make capturing HCCs for risk adjustment a perpetual uphill battle. But it doesn’t have to be.

Healthmap’s Kidney Health Management (KHM) program supports our participating providers with identification of HCC coding opportunities. Our Quality Practice Advisors regularly meet with providers and practice personnel to review patient interventions and any coding opportunities that are present for patients in the KHM program. This information prepares providers to address clinically appropriate codes at the point of care.

With support from Healthmap Solutions, participating providers have access to the expertise and information needed to generate risk adjustment scores that will ultimately reward them for the care they deliver.