Acute Renal Insufficiency

robert.hodges2

Just wondering if anyone out there has a definition and source for acute renal insufficiency. We have confusion here amoung the providers on the difference between "failure" and "insufficiency". I normally request clarification based on the RIFLE criteria, but was wondering if anyone had some good guidelines. A google search pointed to acute renal failure, but nothing clear regarding insufficiency.

For "chronic renal insufficiency" I do ask them to stage it based on the National Kidney Foundation guidelines.

Help?

Robert

Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VA Medical Center

Robert.Hodges2@va.gov
989-497-2500 x13101

Unknown

In the ICD-9-CM renal insufficiency codes to:
(disorder of kidney & ureter)



Charlene

robert.hodges2

So would the best answer be that if it doesn't meet RIFLE criteria for injury or higher, or can't be staged as chronic kidney disease it should be documented as "insufficiency"?

Robert

Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602

Unknown

Physicians should be educated to steer clear of the term Renal insufficiency. Either the patient is in failure or has CKD. Documenting the stage of CKD will improve data integrity and will help clarify these vague terms of "renal insufficiency" or "chronic renal failure. The stages of CKD according to the National Kidney Foundation are as follows:
Stage I: GFR >90
Stage II: GFR 60-89
Stage III: GFR 30-59
Stage IV: GFR 15-29
Stage V: GFR >> CDI Talk 02/04/2010 12:53 >>>
So would the best answer be that if it doesn't meet RIFLE criteria for injury or higher, or can't be staged as chronic kidney disease it should be documented as "insufficiency"?

Robert

Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602

P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov

"To climb a steep hill requires a slow pace at first." -William Shakespeare

dallend@einstein.edu

When our physicians document Renal Insufficiency - I check the labs -if the patient does not meet RIFLE criteria for failure and does not have CKD I will ask them to document the cause of the renal insufficiency. Many times they will document dehydration or some other cause - I request they put the cause in diagnosis terms (sometimes they have to be reminded). At least then the coders have something a little more concrete to code.
If they meet the RIFLE criteria for Failure I will leave them a query asking if it's possible that the pt has Renal Failure and provide the supporting documentation.
Unfortunately when you search for renal insufficiency - most of the time it's used as a synonym for renal failure.
Dr Gold had teleconference a while back on renal failure that had some good information also.

Unknown

There is a HCPRO presentation on Renal Failure Coding and Querying: understand the Clinical Perspective 10/23/09 with Dr. Robert Gold. It is worth a listen.

One of the slides defined each as below:

Renal insufficiency (code 593.9, Unspecified disorder of the Kidney and Ureter) refers to the early stages of renal impairment, determined by mildly abnormal elevated values of serum creatinine or BUN or diminished creatinine clearance. Clinical symptoms or other abnormal laboratory parameters may or may not be present but are usually minimal.

Renal failure (code 584.x Acute) is a progression of renal insufficiency where renal function is further impaired and overt clinical consequences have developed.

In essence, renal insufficiency is more of an abnormal laboratory assessment, while renal failure incorporates both abnormal laboratory and clinical findings.


Hope this helps

Carla A. Heyn, RHIT, BS
Clinical Documentation Specialist
Elliot Hospital
One Elliot Way
Manchester, NH 03103
603-663-3452
cheyn@Elliot-HS.org

robert.hodges2

To follow up then, if they don’t meet RIFLE criteria for Failure, but do meet RIFLE criteria for Injury, do you ask them to consider documenting acute renal injury?



Robert



Robert S. Hodges, BSN, MSN, RN

Clinical Documentation Improvement Specialist

Aleda E. Lutz VAMC

Mail Code 136

1500 Weiss Street

Saginaw MI 48602



P: 989-497-2500 x13101

F: 989-321-4912

E: Robert.Hodges2@va.gov



"To climb a steep hill requires a slow pace at first." -William Shakespeare

dallend@einstein.edu

I usually don't ask for Acute Renal Injury - our physicians will use this term for ARF/AKI. Acute Renal Injury codes to AKI, I believe. I will only ask them to document the cause of the renal insufficiency. They will document what they will document. I don't think ICD 9 is always in sync with some of the diagnoses that we see. We just have to do the best we can.

ctrygar

acute renal failure and acute kidney injury has been an ongoing battle in reguards to definition. I just reviewed a chart that was denied by Blue Cross for Acute Renal Failure. They quoted back to me that the patient didnt qualify for ARF based on the RIFLE staging system. She used the F (failure) which states creatine level needs to increase by x 3.0 to be considered ARF.( pt had a kidney stone cr as high as 1.9 on adm with a 0.9 on discharge) However the nephrologist I spoke with here and literature I read( up to date) stated that the RIFLE system is a staging system for levels of ARF I believe you dont have to be at F level to consider it failure. As is AKI has staging system

stage 1 increase in serum creatine of more than or equal to 0.3 in normal function
or increase to more than or equal to 150-200% (1.5-2.0 fold) from baseline

stage 2 increase in cr 200-300% from baseline

stage 3 increase of > 300%

so AKI stage 1 is similar to ARF (R in Rifle acute change in creatine at least 0.3 or increase x1.5)

So as far as insurance companies are auditing the charts not sure what they are really doing. I havent heard back from them yet.

SoI look at the labs if abnormal per AKI/ARF criteria and they are treating with fluids and/or doing studies such as ultrasounds/ urine cre,osmo,protein. I query the chart.
Does anyone have any other thoughts.

thanks

cheri

robert.hodges2

Cheri,

This is based on a BC denial also, but they said that the patient didn't have three lab. I'm encouraging that we challenge this one and ask for the reference they use that say you have to have three lab values for acute failure. The patient had a 57% decrease in GFR and the creatinine almost doubled from their baseline. I'm waiting to hear on this, but suspect we will win the appeal.

Thanks much all

Robert

Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
 
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
 
"To climb a steep hill requires a slow pace at first."  -William Shakespeare
 

dallend@einstein.edu

We have also had retro denials from payors regarding ARF. We tend to err now on the side of caution at times. The problem at our facility is our residents may document ARF inappropriately. We have to educate them and reeducate them.
We also have a very high population of dialysis and nursing home patients.
I leave the query on the charts with the pt's information and see what happens. Many times they will order a renal consult because they don't know what to document.
I have not heard our renal attendings refer to RIFLE as a staging system for Renal Failure - I will be asking that question of them next week. That could change the way we query.
RE: our denials. At times we have had excellent supporting documentation and we are still denied. Our coding compliance associate is great - she keeps those appeals going!

dallend@einstein.edu

I think I am having a moment!!
We do use the guideline of 1.5 times baseline cr when querying for Acute Renal Failure. There also must be treatment, etc.
If it fits into the RIFLE criteria we will query. We usually are querying to clarify the MD documenting Renal insufficiency - most of the time those patients do not meet RIFLE criteria.