Q&A: Documenting acute renal insufficiency versus acute renal failure

Q: Some CDI specialists tell physicians not to document acute renal insufficiency because it does not code to acute renal failure and I am wondering if that is considered appropriate.

For instance, I was reviewing a chart and the physician documented that the patient had acute renal insufficiency with elevated blood urea nitrogen (BUN) and creatinine levels. I reviewed the labs for renal failure criteria but the patient did not meet the criteria for renal failure, so I did not query for clarification nor did I call the physician to discourage the use of renal insufficiency.

A: We should teach the providers to document the most appropriate diagnosis for the patient. We should not be teaching them to document only the diagnoses we desire to see recorded. The diagnosis of renal insufficiency is a clinically important identification when assessing a patient and planning their care. It simply communicates that the kidneys are functioning poorly and that we must take notice of this when providing care for the patient. We may need to make efforts to increase perfusion or to adjust the patient’s medications or treatments to assure no further decrease in renal function or acute renal failure/acute kidney injury occurs. CDI specialists/ coders should examine the record looking for indicators to support acute renal failure or kidney disease. If there is support, certainly query.

I have two concerns related to telling providers to “not document renal insufficiency, because it doesn’t code out.” First renal insufficiency is a valid diagnosis in the medical field. Recommending physicians omit this documentation puts the CDI team in a position where it could lose credibility. Any number of codes do not provide increased payment, but if such documentation and subsequent code assignment applies to that patient’s condition then the CDI team needs to encourage its documentation.

As I said above, the fact the patient presented with decreased renal function is important to the patient’s treatments and plan of care. Physicians need to communicate this issue to each other to ensure all work to maintain and improve renal function. Telling a provider not to document a valid diagnosis because it doesn’t provide us with a “useful” code, could actually hurt the patient and certainly decrease our effectiveness.

Instead of telling them not to document it, we should teach them that there are a number of codes related to renal function. Providers should differentiate between an acute or chronic dysfunction of the kidneys and then clearly identify the extent of the dysfunction (e.g., staging of chronic kidney disease, extent of the acute dysfunction, insufficiency versus failure). Work with the providers to identify organizational definitions of what is considered acute renal insufficiency and what is considered acute renal failure. Educate providers on the staging of chronic renal disease. Lastly, educate them to identify the etiology of the acute failure to allow for better specificity.

The second issue I see with telling the providers not document a diagnosis (even if it is appropriate) is that it reinforces the assumption by providers that coders and CDI professionals are only concerned with maximizing payment. Our focus should be to capture the most appropriate documentation (diagnoses) for the patient. If we do this and this is our focus, we will assign the most appropriate codes, receive the appropriate payment and our quality scores, risk adjustment, severity of illness/risk of mortality will all be strong.

When providers ask me, “What do you want me to write?” My standard answer was always “I want you to document what is right and true for this patient – this encounter.” If your providers do this, sometimes we will be assigning the code for acute renal insufficiency and sometimes we will be assigning the code for acute renal failure, but we will be assigning the code that is appropriate for this patient, this encounter, every time.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.