Clinical Documentation Improvement Series #12. Documentation of Acute Renal Failure
Acute renal failure is a common condition that occurs in the hospital setting. Usually patients have the issue present at the time of admission, but it can also happen during the hospitalization. Regarding the documentation of the problem, there are some issues that have to be kept in mind in order to pass on the information properly to the coders. The first thing is that the word insufficiency, even as clinicians know what it means, is not an accepted term in coding. If “acute renal kidney insufficiency” is documented when there is a case of renal failure, the hospital we will not be able to include it in the coded diagnoses. The next problem is the use of acronyms. Since “AKI” can also mean “acute kidney insufficiency”, it will not be accepted, unless it is clarified in the chart. The clinical documentation specialists will have to query the providers in order to obtain the clarification, if not present. Another issue is the lack of specificity regarding the cause of renal failure. Tubular necrosis, interstitial nephritis, glomerulonephritis, obstructive uropathy have to be included is the suspicion is there. The terms possible, probable, not ruled out, likely and suspected are acceptable since the patients being treated as if they were having the condition.
Marco A. Ramos MD, CCDS