Recently, we received the following question and follow up questions in the Coding@scanhealthplan.com inbox.
Then, we received a follow up:
Follow up Question:
The instructional notes for 250.40 say:
chronic kidney disease (585.1-585.9)
nephropathy NOS (583.81)
intercapillary glomerulosclerosis (581.81)
Kimmelstiel-Wilson syndrome (581.81)
But you don’t code all those things unless they are documented.
I hope that clarifies.
In response, the questioner indicated that they planned on coding cerebral atherosclerosis (437.0) because:
Multi-infarct(cerebrovascular) ( see also Dementia, arteriosclerotic)"
I don't believe I did a good enough job explaining why you wouldn't code something not documented. But the reality is that cerebral arteriosclerosis is not the only cause of vascular dementia, although it may be the most common cause. Multi-infarct dementia (MID), due to multiple strokes or TIAs, or mixed type due to MID and Alzheimers, or many other