renal insufficency vs renal failure

Unknown
edited May 2016 in CDI Talk Archive
An on call physician documents "acute renal insufficiency due to
vacomycin". 2 days later the attending physician documents "renal
insufficiency/failure".

1. Should I query to clarify if the patient has renal insufficiency
or renal failure?
2. Should I query for acute vs chronic?

Thanks,

Patti


Patti Stewart BSN,RN
Clinical Documentation Specialist
Mercy Medical Center
1301 15th Ave. West
Williston, ND 58801
pattistewart@catholichealth.net

Comments

  • ggoodman@virginiahospitalcenter.comggoodman@virginiahospitalcenter.com
    edited May 2016
    That one is tricky...

    I would query for acute renal failure.

    If you think per other documentation/labs that the pt may have CKD it
    doesn't hurt to Query the CKD stage too.



    Greta Goodman
    Clinical Documentation Improvement Specialist
    Health Information Management
    Virginia Hospital Center
    1701 North George Mason Drive
    Arlington, VA 22205
    703-558-5336
    ggoodman@virginiahospitalcenter.com
  • robert.hodges2robert.hodges2
    edited May 2016
    Absolutely query. Slashes between diagnoses drive coders nuts I have
    found out.

    Also, you may have acute on chronic failure and that should be
    clarified. It is nice you got the underlying cause.


    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


    "The difference between the right word and the almost right word is the
    difference between lightning and the lightning bug." Samuel "Mark Twain"
    Clemens
  • digardskdigardsk
    edited May 2016
    If the findings and the treatment support acute renal failure, I would
    query for that. In addition, if it looks like a chronic condition in
    addition to the acute process, I would query for chronic kidney disease
    (CKD) by stage. Kim
  • mark.domineseymark.dominesey
    edited May 2016
    Another thing to consider… does the failure/insufficiency change the DRG to an toxic effect or poisoning DRG? Just throwing that out there for consideration. Coding it out it looks as if it still is the renal failure DRG, 684, the cause is an E code: E9308.

    If another renal toxic drug was on-board, then, will it change to the poisoning DRG (918)?

    Just some things to think about,

    Mark

    Mark Dominesey, RN/BSN, MBA
    Clinical Documentation Improvement Specialist
    Health Information Management Services
    Martha Jefferson Hospital
    Charlottesville, VA 22902
  • catladyrncatladyrn
    It doesn't seem likely that the toxic effect would be the result of Vancomycin being given incorrectly, but rather, a known side effect of the medication, and therefore, the coding would go to the manifestation (renal failure) and not a poisoning.

    Renee


    Linda Renee Brown, RN, CCRN, CCDS
    Certified Clinical Documentation Specialist
    Banner Good Samaritan Medical Center
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