Renal insufficiency vs Renal Failure

breed@trinityhealth.com

Does anyone educate their physicians on the difference between renal insufficiency vs renal failure? Our confusion is that they are two different MS-DRG's. Our physicians use them interchangably. Can you clarify the difference in these diagnoses or is there a difference?
Thank you, kim

kbartemes@trinityhealth.com

evanspx@sutterhealth.org

High volume topic - acute/chronic/stage of CKD.



Table may be a good reference and tool to build a query - can't send ours as it is copyrighted.



* Acute Kidney Injury/Acute Renal Failure

ddouthit

We received a denial not terribly long ago for ARF and in that denial they quoted RIFFLE criteria. Might also be a good reference tool.

Dorie Douthit, RHIT,CCS
CDI Program/HIM
706-389-3364
St. Mary's Health Care System
1230 Baxter Street
Athens, Georgia 30606

evanspx@sutterhealth.org

Yes - but, I should state the criteria for ARF are somewhat controversial. I have reviewed denials from 3rd parties denying the code for 584.9 even when two conditions have been met:



1. ARF is clearly and repeatedly documented by authorized clinician
2. Cr at admit = 1.8 and fell to 1.1 with IV hydration



In process of appealing, but would advocate you discuss the criteria with nephron and senior leadership





Paul Evans, RHIA, CCS, CCS-P, CCDS



Supervisor, Clinical Documentation Integrity, Quality Department

California Pacific Medical Center

2351 Clay #243

San Francisco, CA 94115

Cell: 415.637.9002

Fax: 415.600.1325

Ofc: 415.600.3739

evanspx@sutterhealth.org

catladyrn

If the clinical indicators are there, I wouldn't just let them get away with using RIFLE criteria to shoot you down, so to speak. AFAIK, there is not yet a gold standard for defining acute renal failure, and there are other opinions, such as AKIN, that define AKI differently. I would look closely at the patient's clinicals, and if you really think they had renal failure, you might think about appealing.

OTOH, I once had a physician document ARF when the creatinine went from 0.8 to 1.1, with no other clinical evidence of renal problems or any treatment. When I questioned him, he said that there was a 0.3 increase in the creatinine and therefore it met AKIN criteria. Just like the physician who always documented NSTEMI for any rise in troponin and VDRF for any patient on a ventilator, even if they had a CABG done an hour earlier. Want to bang my head against the wall sometimes.

Renee

Linda Renee Brown, RN, CCRN, CCDS
Senior Consultant, CDI/Nursing
Jacobus Consulting, Inc.

evanspx@sutterhealth.org

Thanks, Renee - I agree. I did write an appeal on this one citing
the MD clear statement of ARF and the fact the Cr was 1.8 on day one and
fell to 1.1 with medical attention.

I believe the RAC can be 'too aggressive' at times. What concerns me
is that the RAC only stated something like 'this does not meet OUR
definition of ARF" - however, the RAC did not offer a definition they
would 'accept'. Given we used RIFLE; I think the RAC is not correct on
this one.

I believe this indicates we should vigilantly rebut the RAC if/when we
feel we have legitimate cause to do so.



Paul Evans, RHIA, CCS, CCS-P, CCDS

Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org

catladyrn

What I find kind of interesting is a tendency for us to assume that the RAC is some sort of repository of all coding knowledge and that we have to defer to their wisdom. I'm not aware of them having superpowers or crystal balls, so we have every right to step back and say, wait a minute, your interpretation isn't necessarily the right one, and certainly not the only one. If rules were so clear, we wouldn't have so many 5 - 4 Supreme Court decisions.

Of course, we still have to be diligent in getting physicians to bring that clinical into the record. I'm finding that getting the diagnosis written is the easy part; it's getting the clinical to support the diagnosis that's become much more challenging.

Renee

Linda Renee Brown, RN, CCRN, CCDS
Senior Consultant, CDI/Nursing
Jacobus Consulting, Inc.

ddouthit

Well said Renee.

Dorie

evanspx@sutterhealth.org

I suppose some may feel the RAC is a repository of all things clinical
and having the 'last word', but I don't share that view - sometimes the
RAC is correct and sometimes not. Renee, I know you share this view.


From a technical coding point of view, I have found more than a few
instances whereby the RAC stance on multiple issues has been flawed -
either assigned wrong code or applied guidance issued in Coding Clinic
incorrectly.

I am more concerned that CMS, via MedLearn, informs us that even though
a condition such as acute respiratory failure (518.81) is documented, it
was an error to submit the code on a bill - in these correspondences
from MedLearn, no universally acceptable definition for the denied
condition, 518.81, for instance, is offered. I would find such
guidance to the CDI and coding world more palatable if the RAC would
consistently cite and define definitions, such as standard ABG values.


I totally understand that something such as 518.81 might be stated, and
it might be wise to seek confirmation prior to bill drop, but some of
the clinical reviews conducted remotely concern me, particularly when a
'definition' that would satisfy the insurance company or the RAC is not
published by them or offered.


Paul Evans, RHIA, CCS, CCS-P, CCDS

Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org

mdominesey

I attend the daily UR meetings here and this is a recurring topic of conversation. For them, the RACs do not publish or advise as to what guidelines they go by, either Milliman or Intergqual; this is made worse because CMS does not even have an adopted set of guidelines!

On the front lines for CDI, coders, UR people and others, it almost feels like a purposeful ambiguity.

Mark



Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
Sr. Clinical Documentation Improvement Specialist
Sibley Memorial Hospital

Information Technology
5255 Loughboro Rd NW
Washington DC, 20016-2695

W: 202.660.6782
F: 202.537.4477


http://www.sibley.org

evanspx@sutterhealth.org

Mark: Understood - briefly, our strategy is to devise and publish
'acceptable' facility-approved and evidence-based definitions generally
used in Medicine for high-risk diagnoses, such as acute renal failure,
sepsis, acute respiratory failure, and so forth, and to incorporate
these definitions as a part of our query forms that are stored in the
permanent record.

Define ....Document....Defend

We have MD subject-matter experts approve and review our definitions.

I hope this may be a line of defense that is proactive as we deal with
3rd parties.

It seems the RAC won't publish their versions of disease processes as
continuing subjectivity serves their purpose.




Paul Evans, RHIA, CCS, CCS-P, CCDS

Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org

don.cdi.rn@gmail.com

"almost feels like a purposeful ambiguity"
snort, sputter, choke...
coffee onto keyboard...

Perhaps I am too cynical, but most of the time I personally have little doubt about whether the ambiguity is intentional......

On the flip side, would anyone really want a governmental bureaucracy to come up with clinical definitions, guidelines, etc?
At least there is some room to be able to defend one's reasonable position.

Don