ICD-9 presumed a cause-and-effect relationship between chronic kidney disease (CKD) and hypertension even if another cause for the CKD was noted. ICD-10 only assumes a link between CKD and hypertension when the physician does not document another cause for the CKD (e.g. CKD due to diabetes). Please see cases below that illustrate the differences between the previous and current rules:

Case 1: CKD stage 4 linked to diabetes only

Patient with history of CKD stage 4 due to diabetic nephropathy, hypertensive heart disease, and diastolic heart failure presents with severe shortness of breath and diagnosed with acute exacerbation of diastolic heart failure.

DRG 292: Heart Failure with CC – RW: 0.9588

Case 2: CKD stage 4 linked to diabetes and hypertension

Patient with history of CKD stage 4 due to diabetic nephropathy and hypertensive heart disease, and diastolic heart failure presents with severe shortness of breath and diagnosed with acute exacerbation of diastolic heart failure.

DRG 291: Heart Failure with MCC – RW: 1.4799

• Ensuring documentation is clear regarding the causal relationships between hypertension, diabetes, and chronic kidney disease can have DRG implications
• Always review documentation to ensure cause-and-effect relationships are clearly documented, especially when conditions could potentially be due to more than one cause