RE: [EXTERNAL] Renal failure/renal insuff
One of the first things I try to let physicians know is that clinical and coding nomenclature don't always line up exactly, which is why we have to clarify acute coronary syndrome or heart failure with preserved EF. I tell them I don't expect them not to use current clinical nomenclature, but that I need additional documentation to satisfy reporting requirements.
As far as renal insufficiency, if it's chronic, it will code to CKD. But if they document acute renal insufficiency, it's reported as "disorder of kidney and ureter," and I ask them if that's what they meant to describe. Give them some concrete examples of what happens to the DRG and SOI/ROM using acute kidney injury vs. using acute renal insufficiency. And share the criteria, as Robert described, so that they can feel comfortable using the term AKI or ARF for a particular patient. If your institution doesn't have definitions of AKI using RIFLE or AKIN or KDIGO criteria that every physician can follow, you might want to suggest that, as well.
Renee
Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
Director, Clinical Documentation
Tanner Health System
As far as renal insufficiency, if it's chronic, it will code to CKD. But if they document acute renal insufficiency, it's reported as "disorder of kidney and ureter," and I ask them if that's what they meant to describe. Give them some concrete examples of what happens to the DRG and SOI/ROM using acute kidney injury vs. using acute renal insufficiency. And share the criteria, as Robert described, so that they can feel comfortable using the term AKI or ARF for a particular patient. If your institution doesn't have definitions of AKI using RIFLE or AKIN or KDIGO criteria that every physician can follow, you might want to suggest that, as well.
Renee
Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
Director, Clinical Documentation
Tanner Health System