Query questions linger regarding renal failure

Robert S. Gold, MD

If you weren’t at the ACDIS 2009 annual conference you missed Robert S. Gold’s (MD, founder and CEO of DCBA, Inc., in Atlanta, GA) presentation regarding renal disease documentation for clinical indicators.

Physicians don’t explicitly document acute renal failure—a major complication/comorbidity, making it difficult for coders and CDI professionals due to the lack of pertinent clinical details contained in the medical record. Similarly, chronic kidney disease coding and billing frequently suffers the same fate due to lack of documented specificity and risk stratification.

Jennifer Avery, CCS, CPC-H, CPC, CPC-I

Physicians who think they’ve established a link between diabetes and chronic renal failure, in fact failed at the task simply because they haven’t documented this connection clearly enough to satisfy coding guidelines.

ACDIS has a number of resources for CDI specialists struggling with this issue. Members can find Dr. Gold’s 2009 presentation slides on the Forms & Tools Library along with a number of sample query forms and suggestions.

There’s also a number of related articles available to ACDIS members including:

• Case study: When to query for presence of acute renal failure
• Tip: Put on your clinical hat first, coding shoes second
• Use kidney key-words to sooth your documentation troubles

Also don’t miss Dr. Gold’s upcoming audio presentation Renal Failure Coding and Querying: Understand the Clinical Perspective Friday, October 23, 2009, 1 p.m. (EST) with Jennifer Avery, CCS, CPC-H, CPC, CPC-I, senior regulatory specialist with HCPro, Inc. and lead instructor for Certified Coder Boot Camp®—Inpatient Version.