Form Cms-2728-U3 - Esrd Medical Evidence Report Medicare Entitlement And/or Patient Registration Page 3
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6LIST OF PRIMARY CAUSES OF END STAGE RENAL DISEASE
Item 15. Primary Cause of Renal Failure should be completed by the attending physician from the list below. Enter the
ICD-9-CM code to indicate the primary cause of end stage renal disease. If there are several probable causes of renal
failure, choose one as primary. Code effective as of September 2003.
ICD-9
NARRATIVE
ICD-9
NARRATIVE
DIABETES
CYSTIC/HEREDITARY/CONGENITAL DISEASES
25040
Diabetes with renal manifestations Type 2
75313
Polycystic kidneys, adult type (dominant)
25041
Diabetes with renal manifestations Type 1
75314
Polycystic, infantile (recessive)
75316
Medullary cystic disease, including nephronophthisis
GLOMERULONEPHRITIS
7595
Tuberous sclerosis
7598
Hereditary nephritis, Alport’s syndrome
5829
Glomerulonephritis (GN)
2700
Cystinosis
(histologically not examined)
2718
Primary oxalosis
5821
Focal glomerulosclerosis, focal sclerosing GN
2727
Fabry’s disease
5831
Membranous nephropathy
7533
Congenital nephrotic syndrome
58321
Membranoproliferative GN type 1, diffuse MPGN
5839
Drash syndrome, mesangial sclerosis
58322
Dense deposit disease, MPGN type 2
75321
Congenital obstruction of ureterpelvic junction
58381
IgA nephropathy, Berger’s disease
75322
Congenital obstruction of uretrovesical junction
(proven by immunofluorescence)
75329
Other Congenital obstructive uropathy
58382
IgM nephropathy (proven by immunofluorescence)
7530
Renal hypoplasia, dysplasia, oligonephronia
5834
With lesion of rapidly progressive GN
75671
Prune belly syndrome
5800
Post infectious GN, SBE
75989
Other (congenital malformation syndromes)
5820
Other proliferative GN
NEOPLASMS/TUMORS
SECONDARY GN/VASCULITIS
1890
Renal tumor (malignant)
7100
Lupus erythematosus, (SLE nephritis)
1899
Urinary tract tumor (malignant)
2870
Henoch-Schonlein syndrome
2230
Renal tumor (benign)
7101
Scleroderma
2239
Urinary tract tumor (benign)
28311
Hemolytic uremic syndrome
23951
Renal tumor (unspecified)
4460
Polyarteritis
23952
Urinary tract tumor (unspecified)
4464
Wegener’s granulomatosis
20280
Lymphoma of kidneys
58392
Nephropathy due to heroin abuse and related drugs
20300
Multiple myeloma
44620
Other Vasculitis and its derivatives
20308
Other immuno proliferative neoplasms
44621
Goodpasture’s syndrome
(including light chain nephropathy)
2773
Amyloidosis
58391
Secondary GN, other
99680
Complications of transplanted organ unspecified
INTERSTITIAL NEPHRITIS/PYELONEPHRITIS
99681
Complications of transplanted kidney
99682
Complications of transplanted liver
9659
Analgesic abuse
99683
Complications of transplanted heart
5830
Radiation nephritis
99684
Complications of transplanted lung
9849
Lead nephropathy
99685
Complications of transplanted bone marrow
5909
Nephropathy caused by other agents
99686
Complications of transplanted pancreas
27410
Gouty nephropathy
99687
Complications of transplanted intestine
5920
Nephrolithiasis
99689
Complications of other specified transplanted organ
5996
Acquired obstructive uropathy
5900
Chronic pyelonephritis, reflux nephropathy
MISCELLANEOUS CONDITIONS
58389
Chronic interstitial nephritis
28260
Sickle cell disease/anemia
58089
Acute interstitial nephritis
28269
Sickle cell trait and other sickle cell (HbS/Hb other)
5929
Urolithiasis
64620
Post partum renal failure
27549
Other disorders of calcium metabolism
042
AIDS nephropathy
8660
Traumatic or surgical loss of kidney(s)
HYPERTENSION/LARGE VESSEL DISEASE
5724
Hepatorenal syndrome
40391
Unspecified with renal failure
5836
Tubular necrosis (no recovery)
4401
Renal artery stenosis
59389
Other renal disorders
59381
Renal artery occlusion
7999
Etiology uncertain
59383
Cholesterol emboli, renal emboli
FORM CMS-2728-U3 (03/06)
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