• Link hypertension to cardiac and renal disease states
• Document extent of chronic kidney disease (CKD), a condition most commonly due to diabetes and hypertension.
  • Stage 1 – GFR > 90 ml/min/1.73 m²
  • Stage 2 – GFR 60-90 ml/min/1.73 m²
  • Stage 3 – GFR 30-59 ml/min/1.73 m²
  • Stage 4 – GFR 15-29 ml/min/1.73 m²
  • Stage 5 – GFR <15 ml/min/1.73 m²
  • End-stage renal disease (ESRD) – patients with stage 4 or 5 CKD who have been on dialysis for three months

• Document type of congestive heart failure with acuity (e.g., acute, chronic, acute on chronic)

• Types (Not needed for coding. For your reference only.)

  • Type 1 Cardio-Renal Syndrome: abrupt worsening of cardiac function leads to acute kidney injury (e.g., acute congestive heart failure causing acute kidney injury)
  • Type 2 Cardio-Renal Syndrome: chronic worsening of cardiac function leads to chronic kidney disease (e.g., hypertension causing chronic kidney disease)
  • Type 3 Cardio-Renal Syndrome: abrupt worsening of renal function causing cardiac dysfunction (e.g., pyelonephritis causing acute renal failure with fluid overload causing congestive heart failure)
  • Type 4 Cardio-Renal Syndrome: chronic kidney disease causing decreased cardiac function, cardiac hypertrophy and/or increased risk of acute cardiovascular events (e.g., CKD causing hypertension leading to coronary artery disease)
  • Type 5 Cardio-Renal Syndrome: a systemic condition causing both cardiac and renal dysfunction (e.g., sepsis causing acute congestive heart failure and acute kidney injury)

Adult (main)|Pediatrics (main)

Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this content.

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