When a patient is documented with diabetes, CKD stage II and III, what should the coder do?

When documenting diabetes and chronic kidney disease (CKD), it's crucial for coders to ensure that the correct stage of CKD is used to accurately reflect the patient's condition. In this scenario, the presence of both CKD stage II and stage III raises a concern because only one stage should be reported based on the provider's documentation.

Querying the provider to determine the appropriate stage of CKD is important because the coding guidelines require that the most accurate and specific diagnosis should be reflected in the medical record. This ensures that the coding aligns with the patient's current health status, which can impact treatment plans, risk adjustment factors, and insurance reimbursements. Coders need to have this information clarified to provide the most accurate coding for the patient's medical record.

This approach prioritizes accuracy in coding, ultimately leading to better patient care and appropriate resource allocation. Other options may lack specificity or lead to errors in documentation, making it essential to confirm the accurate stage of CKD with the provider to ensure optimal coding practices.