Acute Renal Failure caused by Hyotensive Shock caused by dehydration

mdomineseymdominesey
edited May 2016 in CDI Talk Archive
Hey folks, slow day on CDI Talk.

For the coders among the CDI Talkers: How would you code (principal dx) someone admitted to the hospital (ICU) with ARF caused by Hypotensive shock (w/ Levophed tx) caused by dehydration?

Thanks,

Mark


Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
Clinical Documentation Excellence
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
mdominesey@sibley.org
http://www.sibley.org

Comments

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Codes and sequencing are:

    584.9

    785.59

    276.51

    Note: 785.59 is in the Signs/Symptoms chapter, precluding selection as
    principal diagnosis as etiology is stated. If ARF present at time of
    admit and due to dehydration, the ARF must be the PDX.

    Reference: C. Clinic - 1Q, 2003

    Clarification

    There are some issues with regard to the question in Coding Clinic,
    Third Quarter 2002, page 21, on acute renal failure due to dehydration,
    where the only treatment is IV hydration, and BUN and creatinine return
    to normal. The answer contains the final sentence, "The fact that renal
    function was not investigated or worked up does not affect code
    assignment." This was misleading, in that the renal function in fact
    would be followed based on close monitoring of the fluid intake and
    output, as well as the BUN and creatinine. Fluid monitoring requires
    nursing resources. Even though the only treatment for the acute renal
    failure is IV hydration, no procedures are done to image or evaluate the
    kidneys, and treatment with dialysis is not required, it is still
    appropriate to assign the code for acute renal failure as the principal
    diagnosis. In most instances, when dialysis is not required, rehydration
    corrects the acute renal failure. This would be consistent whether the
    acute renal failure was due to dehydration or another condition.


    Paul Evans, RHIA, CCDS

    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
  • ddouthitddouthit
    edited May 2016
    Mark,

    No ATN or Sepsis indicators? If not, then ARF principal 584.9 with 785.59 for shock (MCC), 276.51 for dehydration.


    Acute renal failure due to dehydration
    Coding Clinic, Third Quarter 2002 Page: 21 Effective with discharges: October 31, 2002
    Question:

    A patient is admitted with acute renal failure (ARF) due to severe dehydration. The patient is treated with IV fluids, and a renal ultrasound reveals atrophic right kidney. The patient slowly improves; however, the family does not want an aggressive workup and the patient is discharged to a hospice. What is the principal diagnosis in this case, ARF or dehydration?

    Answer:

    Note from 3M:
    As of October 1, 2005, code 276.5 has been expanded to the 5th digit. Dehydration is coded to 276.51.

    Assign code 584.9, Acute renal failure, unspecified, as the principal diagnosis. Acute renal failure was the reason for the admission. Code 276.5, Volume depletion, should be assigned as an additional diagnosis.



    Dorie Douthit, RHIT,CCS
  • Unknown
    edited May 2016
    Can you all tell me exactly what indicators to look for when looking for
    ATN? Thanks

    Jamie Dugan RN
    Baptist Health System

    Jacksonville, Florida
  • dvitalone1dvitalone1
    edited May 2016
    ATN is Intrarenal kidney disease which means BUN/Cr ratio LESS than 10:1, serum BUN rises much slower, and you may see epithelial cells in the UA
  • dvitalone1dvitalone1
    edited May 2016
    There is a great presentation from Conference 2012 in the Forms and Tools Library on the ACDIS site by Dr Trey La Charite called "The Kidney Disease Acronym Spectrum: ARI, CKD, AKI, ARF, and ESRD."

    Dawn M. Vitalone, RN
    Clinical Documentation Improvement Specialist
    Community Hospital
    Munster, IN 46321
    dvitalone@comhs.org
    219-513-2611
  • mdomineseymdominesey
    edited May 2016
    Does anybody have a comprehensive chart for AKI/Renal insufficiency much like the ones we see for Malnutrition, Respiratory Failure, or Sepsis? With citation would be great. I am currently writing a query for "Renal Insufficiency" for a patient who has Levophed on board (hypotesion can cause ATN).

    Thanks,

    Mark



    Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
    Clinical Documentation Excellence
    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
    mdominesey@sibley.org
    http://www.sibley.org
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Various Definitions:

    * Interstitial Nephritis - acute: characterized by edema and
    inflammation of the renal interstitium, classically sparing the
    glomeruli and blood vessels; chronic: characterized by interstitial
    fibrosis w/mononuclear leukocyte infiltration and tubular atrophy. Final
    common pathway of many chronic kidney diseases (Practical Guide to the
    Care of the Medical Patient, 8th ed., Fred F. Ferri, MD, FACP, 2010)

    * Glomerulonephritis - an immunologically mediated inflammation
    primarily involving the glomerulus that can result in damage to the
    basement membrane, mesangium, or capillary endothelium (Ferri's Clinical
    Advisor 2011, 1st ed., Fred F. Ferri, MD, FACP, 2011)

    * Acute tubular necrosis (ATN) is defined by acute kidney injury
    and tubular damage in the absence of significant glomerular or vascular
    pathology. Tubular casts, red cells, and protein may be seen in the
    urinanalysis. If the offending agent is removed, the kidneys usually
    repair themselves. (Robbins Pathology)

    * Acute Cortical Necrosis- caused by ischemic necrosis of the
    cortex with sparing of the medullary pyramids. (Grainger & Allison's
    Diagnostic Radiology, 5th ed., Andy Adam, 2008)

    Paul


    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
  • megan.bartonmegan.barton
    edited May 2016
    Paul,

    Thank you!! I am sharing this with my team.

    Megan

    Megan Barton RN, BSN
    Manager Clinical Documentation Improvement
    Health Information Management-Mercy East
    Ph: 314-251-6192
    Fx: 314-251-3982
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Also, specific to ATN, we look for:



    * Protein/cell cast in urine

    * Urine Sodium > 40

    * Fraction Excretion of Sodium >2%, but I have also seen a value
    of greater than > 3% cited as well



    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
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