Further specificity on Acute Renal Failure (ARF)/Acute Kidney Injury (AKI) has become a larger topic with the coding changes that took place October 1, 2010. Personally, I am concerned about being able to ask for clarification when it is actually clinically appropriate to do so versus asking every time any sort of acute renal dysfunction is identified. In that light, I would like to point toward a couple of references I found helpful. (The links to the source material I used as the basis for this discussion are below.)
After reading several resources, it is clear to me that acute tubular necrosis (ATN) in some/many cases is further along a spectrum from ARF. In other words, some of the pre-renal causes of ARF can lead to damage of the kidney and thus develop into ATN. So, all ATN are ARF but not all cases of ARF are also cases of ATN.
CDI specialists should be on the lookout for cases where there is a specified cause for ARF that is not ATN but may be able to be captured with the ICD-9-CM code 584.8, other specified pathological lesion of kidney. According to the sources listed below, common causes of ATN include:
Ischemic (includes some pre-renal causes that are prolonged or severe; occurs when not sufficiently perfused for a long period of time)
- Hypotension (significant; typically greater than 30 minute duration hypotensive episode)
- Major surgery
- Hemorrhagic shock
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Aminoglycoside antibiotics
- Free myoglobin or hemoglobin
Instances of toxic ATN are more likely to develop with co-morbidities such as pre-existing chronic kidney disease or diabetes.
Although the patient may be asymptomatic some signs and symptoms include edema/weight gain, uremic symptoms (anorexia, N/V, AMS, etc.), respiratory (shortness of breath, crackles, x-ray findings) and decreased urine output.
Common diagnostic tools include Fractional excretion of sodium (greater than two ( > 2)); UA with casts (not hyaline); blood urea nitrogen (BUN) (mg/dL) and serum creatinine (mg/dL) values/trends and ratio (ATN for 10-15:1, pre-renal greater than 20:1. Electrolytic changes, especially hyperkalemia and metabolic acidosis may be seen. Renal biopsies are helpful, not but not commonly performed.
Treatment is essentially supportive. It is important to differentiate ARF versus ATN. With ARF the typical cause is volume, so treatment is focused around volume replacement. With ATN, the physician will need to identify underlying cause and address that cause in the patient’s treatment.
In my experience, ATN generally takes longer for renal function to return to baseline. If you see BUN/Cr returning to baseline in less than 48 hours, it is more likely to be ARF due to prerenal causes that rapidly respond to volume replacement.
Here are the sources I mentioned earlier. Don’t forget it always makes good sense to check with your own physicians to see what resources they use.
Many of the nation’s hospitals now have clinical documentation improvement (CDI), management, or integrity programs. They are designed to help physicians improve the documentation of diagnostic or procedural information in inpatient medical records so that the documentation meets the needs of the coding process. There are good things that can come out of these programs, but there can also be bad things.
The first thing for the physician to know is that, if done correctly, a CDI program is one of your best friends. When coders correctly assign the ICD-9-CM (and soon ICD-10) diagnosis and procedure codes, physicians get the following benefits:
- Proper and accurate representation of patient morbidity and mortality statistics
- Proper and accurate representation of physician’s thought processes and actions in treating the patient so that physician billing—as well as the hospital’s—is accurate
- Increased communication among the healthcare providers in dealing so that the most expeditious care can be rendered
- Improved documentation of physician’s daily thought processes in treating patients or those for whom physician’s are consulting
Let me tell you about some things to look out for, however, because you should probably not participate in the following scenarios:
- Acute blood loss anemia. After a hip fracture repair, you may see that the 76-year-old female patient’s hemoglobin dropped from 14 to 12.5 and stabilized. If someone asks the physician to document “acute blood loss anemia,” that’s a problem. First, the patient is not anemic, so it’s unethical. If the patient’s hemoglobin drops from 14 to 8.5 and she becomes tachycardic and physician decides to either transfuse or provide an iron supplement after discharge, call it “anemia due to acute blood loss from the hip fracture.” That tells the story properly.
- Acute respiratory failure. If a patient comes to your service on the cardiovascular ICU after a coronary artery bypass graft and is on a ventilator because of morbid obesity, and early extubation would likely lead to problems, don’t document “acute respiratory failure.” The patient is sedated and maintained basically anesthetized on purpose, not due to a disease. Use “ventilator management” in your documentation. However, if the patient develops a disease and must be reintubated, acute respiratory failure becomes appropriate.
- Systemic inflammatory response syndrome (SIRS). The criteria for a significant infection that the Society of Critical Care Medicine put out in 1991 have undergone considerable modification. Can you recall any patient with acute cholecystitis or acute appendicitis who has not had two of the four criteria of SIRS? Have any of your children had a middle ear infection and did not have a fever and tachycardia because it hurt? Did your child need to be on a critical care unit with a central line, or did he simply need some amoxicillin? SIRS is built into bacterial infections. Don’t describe abnormalities in vital signs or lab results in a patient with a simple bacterial infection as SIRS. When a patient has sepsis, you can tell from across the room. Call that sepsis! Reserve SIRS for noninfectious conditions such as significant burns or necrotizing pancreatitis.
- Acute kidney injury (AKI). The Acute Kidney Injury Network has written an exhaustive treatise on what is still often referred to as acute renal failure. When a patient has simple dehydration and small bumps in the creatinine level and everything else returns to normal within six hours of fluid resuscitation, it was not AKI. Should an increase in creatinine level from dehydration persist after initial rehydration, then it was AKI. If it resolves, it was dehydration, prerenal azotemia, or acute renal insufficiency.
- Acute on chronic systolic heart failure. You probably have many patients in your practice who are chronic heart failure (CHF) patients. The specificity of left, right, or biventricular heart failure is important. If you see a patient in your office with left heart failure, differentiate whether it is characterized by systolic or diastolic dysfunction or both. When a patient is admitted to the hospital for acute CHF, document it as “decompensated” plus the chronic state that you know from your office and the echo performed a month ago. If it’s apparent, also document the cause of the acute decompensation. In the hospital, “decompensation” or “exacerbation” is sufficient.
- Encephalopathy. This is simple. If the patient has a condition that caused encephalopathy, call it whatever specific encephalopathy you can. A person who is simply drunk does not have encephalopathy. A person who took a dozen Elavil as a suicide attempt is tranquilized. These are not encephalopathy.
The issues above mean a lot for you, your patients, and the nursing staff. They’re important in the office as well as the hospital. When a CDI staff member asks a good question that improves informational value, provide all the help you can. But when you are asked to document something you don’t believe in or something unsupported in medical literature, think twice.
Editor’s Note: This article first appeared in the January 2011 edition of Medical Records Briefing.
The American Health Information Management Association (AHIMA) released its Ethical Standards for Clinical
Documentation Improvement (CDI) Professionals paper earlier this year. Hopefully, the majority of CDI professionals have taken the time to read the document in its entirety and have assimilated the material to your business practice of CDI. If you have not had the opportunity to read AHIMA’s CDI ethics brief, now is the time to clear off your desk and begin the task.
The AHIMA paper highlights key provisions of ethical standards governing the practice of CDI that serves as an underlying foundation of our profession. These ethical standards are based on the AHIMA’s Code of Ethics, its Standards for Ethical Coding, as well as the Association of Clinical Documentation Improvement Specialists’ (ACDIS) Code of Ethics.
Common sense points governing the roles, duties, and responsibilities of a CDI specialists are presented within the paper. While the information provided is certainly logical and congruent with the philosophy that we ascribe to as CDI professionals, it is worth mentioning several items that may need reiteration from a practical application standpoint. Consider the following:
- CDI specialists shall use queries as a communication tool to improve the quality of health record documentation, not to inappropriately increase reimbursement or misrepresent quality of care
- CDI professionals shall not query the provider when there is no clinical information in the health record prompting the need for a query
- CDI professionals shall facilitate documentation that supports reporting of diagnoses and procedures such that the organization receives the optimal payment to which the facility is legally entitled, remembering that it is unethical and illegal to increase payment by means that contradict regulatory guidelines
- CDI professionals shall not misrepresent the patient’s clinical picture through intentional incorrect documentation or omission of diagnoses or procedures, or the addition of supported diagnoses or procedures to inappropriately increase reimbursement, justify medical necessity, improve publicly reported data, or qualify for insurance policy coverage benefits.
These points on face value appear to represent a philosophy that we consistently ascribe to in carrying out CDI efforts. However, in our quest to secure specific, accurate, and detailed clinical documentation in support of a “complete” record, we may be circumventing the clinically accurate and clinically relevant aspect of CDI.
The Thanksgiving holidays are often filled with excesses. There is the obvious food and drink extravaganza; the all day football watching; the exhausting shopping on black Friday; the unsolicited parental advice, the crying children and of course the many pounds gained.
The holidays also account for a greater incidence of depression, stress, substance abuse and suicide. The numbers of people choosing to take their own lives is increasing. By some estimates a person tries to take their life every 39 seconds. Suicide is not limited to a single age group, racial group, or socioeconomic class. Currently, among the 15- to 19-year olds, suicide is the second leading cause of death (following accidents). The suicide rate has tripled over the last 30 years in this age group. The elderly (often following the death of their spouse, or favorite pet) are another large group very much at risk. (Kirsti A. Dyer, MD)
There are conflicting reports as to whether the suicide rate increases during the holiday, or afterwards. Whether or not there is an increased incidence of suicide, we know there is an increased incidence of depression, mental health visits and the blues, both during the holiday and up to three weeks after the holidays.
Clinical documentation specialists need to be aware of the specialized documentation needs when dealing with substance abuse and the rules that govern the admission of a patient with an overdose.
Physicians historically document “history of drug use” when a patient is admitted, regardless of whether the patient has a current positive drug screen. The physician must be educated on the benefit of documenting drug use/abuse ongoing. The capture of this diagnosis is a comorbidity and therefore, reflects the extra resource consumption and increased severity of illness that these patients possess.
Drug overdoses or the admission for affects of drugs taken with alcohol, are coded to DRG 917-918-Poisoning and toxic affect of drugs.
Similar comorbidities include ETOH withdrawl delirium, ETOH or drug withdrawl, ETOH induced persisting dementia, ETOH induced psychotic disorder with hallucinations, and ETOH mania, psychosis, or mood disorder.
May your holidays be blessed and may you have a wonderful Thanksgiving holiday .
Halloween is almost upon us and it is during these spooky times that many a CDI specialist is most at risk of witnessing one of the most horrific sights in the hospital setting. It is the documentation of failure to thrive (FTT) and altered mental status (AMS). The documentation of these two diagnoses can cause many a seasoned professional to shriek and shake.
Queries are left and sometimes replied to, but many physicians view these forms as pesky little goblins and not the beautiful gems that they truly are. Clinical documentation specialists are good witches not bad ones. (Think wizard of OZ)
Try as we might, it is difficult to retrain many physicians to alter their old documentation habits. They have been writing this way for so long that they are not cognizant of the possible harm this may cause.
Does this patient with AMS actually have an state of acute confusion state or are they a patient with Alzheimer’s related dementia with behavioral disturbance or is the patient suffering a drug induced delirium or is it a case of encephalopathy?
Similarly, the physician needs to determine if the patient with FTT actually have cachexia, intestinal malabsorption, or malnutrition.
There is no trick. All that is needed is a definitive diagnosis, not a symptom. But there is a potential treat waiting those who appropriately document more specific diagnosis. Such documentation can positively affect the physicians’ risk of mortality and severity of illness ratings. It can increase a estimated patient’s length of stay, and comorbid or major comorbid conditions and they may better reflect the E&M billing level for severity.
I received this little condolence card a few weeks ago from an ACDIS member who wishes to remain anonymous. The sentiment concerning CMS’ decision to reduce the classification of ICD-9-CM code 584.9 (acute renal failure, unspecified) from an MCC to a CC, maintains hope for a miraculous resurrection of the dead.
“Thanks for sharing my grief. Although planning the funeral and accompanying eulogies, right now I nevertheless
pray for the resurrection of my dear friend Mr. Acute Renal Failure, Unspecified by the powers of CMS (backed by popular demand). We are rallying his relatives, i.e. Mr. Acute Renal Failure with ATN, Ms. Acute Renal Failure with Renal Cortical Necrosis to continue his legacy as an MCC. I have many fond memories of ARF, he saw me though a lot of challenges and frequently helped me to get me to a higher-weighted and higher-severity MS-DRG. ARF, may you rest in peace!”
The ACDIS Advisory Board sent its recommendations regarding the matter to CMS (published in the July edition of the CDI Journal) to no avail. In the letter, ACDIS Director Brain Murphy wrote: “We note that the current definition of 584.9 is inadequate to identify true MCC cases and the cost of the resources used to treat these severely ill AKI patients… ACDIS proposes that CMS postpone this reduction in classification until the existing code set is refined to encompass patients in various stages of acute renal failure.”
There continues to be debate regarding clinical indicators and definitions for chronic kidney disease and acute renal failure. On Tuesday, November 9, at 1 p.m. EST, join William E. Haik, MD, director of DRG Review, Inc., and Garry L. Huff, MD, CCS, who served as the government liaison for the American College of Physicians on the Editorial Advisory Board for Coding Clinic for ICD-9-CM and later the AHA’s Coding Advisory Panel for the 90-minute audio conference Acute and Chronic Renal Failure Documentation: Understand the Clinical Indicators for Querying and Coding Accuracy. For reservations, call 800/650-6787 or e-mail firstname.lastname@example.org.
The following represent a few additional resources to help CDI professionals better understand the nuances of the issues:
In March 2008, the National Kidney Foundation (NKF) sent a letter to the National Centers for Health Statistics and asked that the term “acute kidney injury” (AKI) be an optional phrase for assigning ICD-9-CM code 584.9 (i.e., that it was the current terminology for what used to be called “acute renal failure.”) The request was granted.
CDI specialists and coders looked at the definitions published through the Acute Kidney Injury Network and noted the criteria of stages 1, 2 and 3 of AKI. They began to ask physicians to document AKI whenever a patient’s labs or urine output met those criteria. But in so doing we hurt ourselves—and we hurt “acute renal failure.” And it’s a shame. Now, with CMS’ resulting reduction of acute renal failure to CC, it now has no more severity attached to it than a simple urinary tract infection.
Let’s see where we went wrong and where we have to go to get it right.
What AKI was
Long ago, in a galaxy far, far away, we had the terms “acute renal insufficiency” and “acute renal failure,” and we had advice as to when
each was appropriate terminology to use in order to assign the codes that were designed for those conditions. These codes included 593.9 for renal insufficiency and 584.9 for acute renal failure (notice I didn’t use the term “acute” in the description of 593.9—it was a nonessential modifier then).
In the medical textbooks and within the medical community there was confusion in the terminology. For example, one medical textbook called the disease “renal insufficiency” and talked about “progressive renal failure,” and another textbook had a chapter entitled “renal failure” and spoke of “anemia of renal insufficiency.”
AHA’s Coding Clinic for ICD-9-CM, First Quarter 1993, p. 17, gave us the following definitions as guidance:
“Renal insufficiency: It is generally accepted that renal insufficiency (code 593.9, Unspecified disorder of the kidney and ureter) refers to the early stages of renal impairment, determined by mildly abnormal elevated values of serum creatinine or BUN or diminished creatinine clearance. Clinical symptoms or other abnormal laboratory parameters may or may not be present but are usually minimal.
The treatment of renal insufficiency depends to a very large extent on the underlying cause, with much attention given to the possibility of preventing progression to renal failure.”
And on p. 18, Coding Clinic states:
“Renal failure: Renal failure (code 584, Acute renal failure, code 585, Chronic renal failure, code 586, Renal failure, unspecified) is a progression of renal insufficiency where renal function is further impaired and overt clinical consequences, such as anemia, have developed. In essence, renal insufficiency is more of an abnormal laboratory assessment, while renal failure incorporates both abnormal laboratory and clinical findings.”
Back then, we looked for more than dehydration. We looked at more than a minor bump in creatinine. We looked for a sick patient. Sure, there may have been obstruction due to prostate cancer associated with a high creatinine level which returned to normal soon after suprapubic tube insertion.
Yes, there may have been a patient found down for three days at home who came in with depressed mental status and rhabdomyolysis and responded to a couple of liters of IV fluids in a couple of days. And these patients came back, at least measurably, to normal. But they were sick and they had acute renal failure. And if a patient had two days of diarrhea “altered mental status” and responded to a glass of water to return the creatinine level to normal, we were happy with dehydration or prerenal azotemia or acute renal insufficiency—because that’s what is was.
During this time, the renal world recognized the problems with lack of consistency and did some studies of acute decrease in renal function. It came up with mortality rates, rates of need for Renal Replacement Therapy (RRT – or dialysis) and identified three pretty distinct levels of change in creatinine, change in Glomerular Filtration Rate (GFR), and change in urine production. It also identified two levels of long-term outcome: Return of measurable function, or no return of measurable function. They published their results and findings and called the system RIFLE. And all rejoiced.
CDI as pointed out by AHIMA in their Clinical Documentation Improvement Toolkit is as follows:
- “The purpose of a CDI program is to initiate concurrent and, as appropriate, retrospective reviews of inpatient health records for conflicting, incomplete, or nonspecific provider documentation. These reviews usually occur on the patient care units or can be conducted remotely (via the EHR).
- The goal of these reviews is to identify clinical indicators to ensure that the diagnoses and procedures are supported by ICD-9-CM codes. The method of clarification used by the CDI professional is often written queries in the health record. Verbal and electronic communications are also methods used to make contact with physicians and other providers. These efforts result in an improvement in documentation, coding, reimbursement, and severity of illness (SOI) and risk of mortality (ROM) classifications.”
I recently wrote an article for this forum on clinical documentation improvement discussing my concern with programs which mainly focus on capturing the Almighty “CCs” and “MCCs” and those programs who teach their CDI staff to make sure they receive “credit” for the resulting capture of said CC or MCC for the initiated query.
In fact, I noticed a post on CDI Talk last month that generated quite a stir regarding so-called “credit for queries” that stirred my attention. Specifically, a coding department was receiving “credit” for physicians who positively responded to queries when the CDI staff conducted the front-end work generating the query. What a disheartening feeling to see firsthand evidence of territorial working relationships between the coding department and the clinical documentation improvement specialists.
Instead of devoting precious energy on fighting over who gets “credit” for securing a CC or MCC, let’s set our minds to the real role of CDI—clinician education on the merits of specific, accurate, and detailed documentation to affect positive change in general patterns of physician documentation. In essence, I believe we should focus on successfully engaging the physician to effectively change their documentation behavior patterns.
The Perpetual Treadmill
If you find yourself constantly leaving the same type of clinical clarification query such as the type of congestive heart failure, the stage of
chronic kidney disease, the type of pneumonia or if you consistently have to query the physician to “rule in” or “rule out” a diagnosis, consider a different approach. This may signify an opportunity to extol the direct impact of appropriate documentation on the physician’s business and on his or her practice of medicine. It provides CDI programs with an opportunity to explain to the physician that CDI programs aren’t simply about more documentation but more effective, clinically accurate, documentation which ultimately leads to better patient care.
Take the following interaction between a CDI specialist and physician, a verbal query that resulted in a principal diagnosis clarification:
A patient was admitted for acute abdominal pain which waxed and waned but in the last two days had become so intense the patient came to the ER. A provisional diagnosis of acute pancreatitis was documented in the initial history and physical (H&P) on the basis of abnormally elevated liver enzymes. Patient received IV hydration and pain meds over the course of the next three days, abdominal pain subsided to the point patient was stable and discharged on day four.
The CDI specialists appropriately left a query for the physcian to clarify the physician’s clinical thought process of acute pancreatitis but unfortunately there was no response from the physician. Not surprising in our line of work! This record went to coding after discharge without clarification. So the coding/CDI staff had to “chase down” the physcian for clarification of principal diagnosis after the fact. In so doing, the CDI specialist carries the record around all day long along with a laptop computer hoping to “catch” the physician on rounds and resolve the matter with a verbal query.
At this point, the physician asks: “How many times do I have to document a diagnosis in the record to avoid these queries.” CDI specialist tells the physician that he/she needs to document the diagnosis at least twice to avoid coders questioning the diagnosis, necessitating a query.
Let’s look at this case again to see if we can identify the missed physician education opportunity.
The American Hosptial Association Coding Clinic cites numerous instances where coders are instructed to query the physician so it is important that you have the tools to do so. That’s why ACDIS members graciously donate samples of their query forms for the association to post on the Forms & Tools Library.
The latest batch of queries comes from Susan A. Klein, BSN, RN, C-CDI, director of clinical documentation management at Saint Peter’s University Hospital in Monroe Township, NJ. Klein included query samples regarding:
- staging for chronic renal failure
- unspecified chest pain
- congestive heart failure
- debridement documentation
Although Klein expects to update her congestive heart failure form to include some core measures information in 2011 the sample provided does offer an interesting checklist of potential diagnoses that could increase the specificity of the medical record. Klein created the forms herself, based on her experiences in CDI and the documentation improvement program she implemented at SPUH. Each form was discussed at its respective medical division and approved by the facility forms committee and medical record committee for their approvals as well.
As with all the forms and other items included in the ACDIS Forms & Tools Library, Klein’s donations are intended as a sample only and any diagnostic criteria should meet the approval of your medical staff and compliance team. “As you know every hospital is unique,” says Klein. “This works well for us here.”
Hello ACDIS members,
I’m pleased to tell you that the CDI Journal special supplement Coding Clinic Update is now available for download. This supplement provides critical updates on the second quarter 2010 AHA Coding Clinic for ICD-9-CM of which all CDI specialists should be aware.
The author of the supplement is James S. Kennedy, MD, CCS, managing director for FTI Healthcare.
This quarter’s issue includes updates related to the use of cancer staging forms, BMI, and far-reaching issues surrounding the coding of gross hematuria due to prostate cancer.
ACDIS members can download the supplement here: http://www.hcpro.com/acdis/details.cfm?topic=WS_ACD_JNL&content_id=255433.
If you have any questions or comments, please feel free to leave them here or you can e-mail Dr. Kennedy directly. His e-mail address is located at the end of the document.