An explicit unrelated-condition statement

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

Chart gym · Original fictional record

Service date: 2026-08-28 · 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 returns to the office for review of two established conditions: hypertension and chronic kidney disease. Both influence the clinician’s plan.

Record clarification

The signed assessment explicitly states that the chronic kidney disease is unrelated to hypertension. The CKD stage is documented as stage 3b.

Care plan

The clinician continues to manage the two conditions separately. There is no new acute kidney diagnosis and no documented heart failure.

Task boundary

The exercise asks how the relationship statement changes coding. It does not ask the learner to dispute the provider’s clinical conclusion or estimate a stage from a laboratory value.

Your coding worksheet

Extract the provider’s relationship statement without changing its meaning.
Compare it with the exception in the hypertensive CKD guideline.
Explain whether the presumed relationship still applies.
Investigate each supported diagnosis and verify its complete entry.

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

The record expressly states that CKD and hypertension are unrelated.
The specific guideline excludes hypertensive CKD coding when the provider indicates that the CKD is unrelated.
The default relationship does not override this explicit statement. Supported separate coding must be investigated.
Retain the documented stage and encounter relevance; do not infer additional heart or acute kidney disease.

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

Practice the linked chart questions