Hypertension with documented CKD stage

Read an original fictional chart, identify the supported facts, and explain your coding workflow.

Chart gym · Original fictional record

Service date: 2026-08-26 · Outpatient professional service

Use your code books and write your reasoning before opening the walkthrough. This exercise contains no real patient information.

Reason for visit

The patient attends a physician office for management of hypertension and chronic kidney disease. Both conditions affect today’s treatment planning.

History reviewed

The established kidney diagnosis is stage 3a chronic kidney disease. Hypertension remains active. The record contains no diagnosis of heart disease and no statement that CKD is unrelated to hypertension.

Assessment and plan

The clinician reviews blood-pressure management and kidney-related medication considerations. The signed assessment retains hypertension and stage 3a CKD. No acute kidney failure is diagnosed.

Abstraction task

Identify the diagnosis relationship and required stage detail. Do not infer heart failure, a different CKD stage or acute kidney failure from the presence of chronic disease.

Your coding worksheet

Identify the two active diagnoses affecting this encounter.
Find the specific hypertension/CKD relationship instruction.
Explain why a CKD-stage entry is still needed and why a heart-and-kidney category is unsupported.
Verify the full candidates in the Index and Tabular List.

In your notebook, record the supported facts, your index route, the instructions you checked, and any missing detail that limits your answer.

Compare with the worked explanation

Hypertension and stage 3a CKD are both established and relevant to the care provided.
The classification presumes the hypertension/CKD relationship unless the provider documents otherwise.
Investigate hypertensive CKD with the additional CKD-stage entry. There is no documented heart disease to support the combined heart-and-kidney pathway.
The worksheet supplies a framework. Confirm the complete code characters and applicable instructions in the current classification.

Reference sections: I.C.9.a.2

Practice the linked chart questions