6.05: CKD with Impairment of Kidney Function

Exact text

6.05 Chronic kidney disease, with impairment of kidney function, with A and B:

A. Reduced glomerular filtration evidenced by one of the following laboratory findings documented on at least two occasions at least 90 days apart during a consecutive 12-month period:

1. Serum creatinine of 4 mg/dL or greater; or
2. Creatinine clearance of 20 ml/min. or less; or
   
3. Estimated glomerular filtration rate (eGFR) of 20 ml/min/1.73m2 or less.

AND

B. One of the following:

1. Renal osteodystrophy (see 6.00C3) with severe bone pain and imaging studies documenting bone abnormalities, such as osteitis fibrosa, osteomalacia, or pathologic fractures; or
2. Peripheral neuropathy (see 6.00C4); or
3. Fluid overload syndrome (see 6.00C5) documented by one of the following:
   1. Diastolic hypertension greater than or equal to diastolic blood pressure of 110 mm Hg despite at least 90 consecutive days of prescribed therapy, documented by at least two measurements of diastolic blood pressure at least 90 days apart during a consecutive 12-month period; or*
   2. Signs of vascular congestion or anasarca (see 6.00C6) despite at least 90 consecutive days of prescribed therapy, documented on at least two occasions at least 90 days apart during a consecutive 12-month period; or*
      1. Anorexia with weight loss (see 6.00C7) determined by body mass index (BMI) of 18.0 or less, calculated on at least two occasions at least 90 days apart during a consecutive 12-month period.

What you must show

• Part A (kidney function): At least two qualifying labs 90+ days apart within 12 months:
  • Serum creatinine ≥ 4 mg/dL, or
  • Creatinine clearance ≤ 20 ml/min, or
  • eGFR ≤ 20 ml/min/1.73 m².
• Part B (complications): At least one documented complication as defined:
  • Renal osteodystrophy with severe bone pain and imaging proof, or
  • Peripheral neuropathy, or
  • Fluid overload syndrome despite prescribed therapy, shown by refractory high diastolic blood pressure (≥ 110 mm Hg on two dates 90+ days apart) or documented anasarca/vascular congestion on two dates 90+ days apart, or
  • Anorexia with weight loss: BMI ≤ 18.0 on two dates 90+ days apart.

Key definitions

• eGFR: An estimate of kidney filtering capacity derived from serum creatinine plus age/sex/body size.
• Creatinine clearance: A calculated or measured estimate of kidney function (24-hour urine or formulas).
• Renal osteodystrophy: Bone disease caused by CKD-related mineral imbalance; look for DXA, X-rays, or other imaging showing osteomalacia/osteitis fibrosa/pathologic fracture.
• Anasarca: Generalized, often severe edema (swelling) throughout the body.
• Fluid overload syndrome: Congestive signs (edema, shortness of breath, vascular congestion) despite therapy.

Proof tips

• Track labs over time: pull eGFR, creatinine, creatinine clearance values from the lab portal and set them on a timeline to confirm the two-tests/90-days rule.
• For Part B, do not rely on impressions alone—submit:
  • Imaging for bone disease (X-ray, DXA, bone scan) and notes describing “severe bone pain.”
  • Neurology notes or EMG for neuropathy where available.
  • Blood-pressure logs showing refractory diastolic hypertension despite treatment, or repeated notes describing anasarca/vascular congestion.
  • BMI calculations done in-clinic that meet the threshold twice 90+ days apart.
• Document Adherence: medications (RAAS blockade, diuretics, phosphate binders, vitamin D analogs), dietary restrictions, and missed-appointment reasons. SSA looks for “despite prescribed therapy.”