Coding Specificity

lori.santonlori.santon
edited May 2016 in CDI Talk Archive
Hello All,

We were hoping for some guidance for this example we are dealing with: ARI documented in progress notes and then in later notes AKI documented.

Would we always need to query for clarification or can we code to highest level of specificity? Are there specific supporting guidelines or coding clinics that you use regarding coding to the highest specificity?

Thank you,
Lori, Elizabeth and Donna
UMass Memorial Medical Center

Comments

  • ddouthitddouthit
    edited May 2016
    In the case where Acute Renal Insufficiency and Acute Renal Failure are documented. If ARF is indicated based off our RIFLE criteria we have chosen as a facility to use, we ask for a clarification of conflicting documentation. This is usually a verbal conversation with the physician. If upon the discharge summary, Acute Renal Insufficiency is documented we then issue a retrospective query for clarification. Acute Renal Insufficiency codes out to 593.9 Acute Renal Failure NOS codes out to 584.9. The terms are not synonymous from a coding perspective.


    Dorie Douthit RHIT,CCS
    ddouthit@stmarysathens.org

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Similar here, further, the abbreviation "AKI" means? Acute Kidney Injury or Insufficiency? Our facility does not code AKI to 584.9, Acute Renal Failure. AKI is an abbreviation that may be interpreted in more than one fashion.



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

    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    evanspx@sutterhealth.org

  • elizabeth.enright@umassmemorial.orgelizabeth.enright@umassmemorial.org
    edited May 2016
    Thank you all for your answers. We would query for clarification when the documentation is conflicting, definitely. The underlying question was to see if there were any guidelines or coding literature to support coding to the highest specificity of a diagnosis based upon the understanding that the code must be precise. Ex: throughout the chart, ARF is clearly documented but in the discharge summary, Acute Renal Insufficiency is documented. Could we code the ARF as it is clear and concise in the body of the record or do we need to query because of the DC summ?

    Thanks,
    Elizabeth Enright, BSN CDS
    UMMHC

  • dvitalone1dvitalone1
    edited May 2016
    I have a question. If "AKI" is on our hospital approved abbreviation list as Acute Kidney Injury, do we still need to seek clarification?


    Dawn M. Vitalone, RN, CCDS
    Clinical Documentation Improvement Specialist
    Community Hospital

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    IMO, no - the abbreviation is listed and defined as Acute Kidney Injury in your approved list. It should only mean 584.9, therefore.

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

    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    evanspx@sutterhealth.org

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    I would query for conflicting dx if the less severe dx is what was documented in the d/c summery.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404

  • ddouthitddouthit
    edited May 2016
    I agree with Katy, I would query as well. Acute Renal Insufficiency and Acute Renal Failure are conflicting diagnosis.

    Dorie Douthit RHIT,CCS
    ddouthit@stmarysathens.org

  • jolene.filejolene.file
    edited May 2016
    I would definitely query if it was documented as acute renal insufficiency on the discharge summary instead of ARF.    There is a coding guideline to code to the highest level of severity but with it being documented as both insufficiency & failure could be considered conflicting.  If only cc on case, an auditor could question and than you would have to defend the diagnosis.
     
    Jolene File,RHIT,CCS,CPC-H,CCDS
    Documentation Improvement Specialist-Coder
    Hays Medical Center
    jolene.file@haysmed.com

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