Health Information Management

Take time to understand acute kidney injury versus acute renal failure

HIM-HIPAA Insider, December 14, 2010

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It’s the classic case of being “lost in translation.”

The language physicians use to create a patient’s clinical picture doesn’t always translate into congruent ICD-9-CM codes. This often leaves coders dazed and confused regarding how to most accurately code the scenario.
Renal functional impairment, such as acute kidney injury (AKI) or acute renal failure (ARF), is one of many syndromes that require coders to understand physician lingo, says James S. Kennedy, MD, CCS, managing director of FTI Healthcare in Brentwood, TN.
The following tips will help you educate physicians and clarify documentation of acute renal dysfunction: 
  • Study up on clinical criteria for AKI and ARF. Coders must be familiar with two prevailing definitions of AKI and ARF, as discussed in the following criteria:
    • Acute Kidney Injury Network (AKIN),
    • Acute Dialysis Quality Initiative Group,
    • However, know that these criteria also have inconsistencies, says Kennedy. For example, many physicians classify patients as having AKI who technically only meet RIFLE criteria for acute kidney “risk,” he says.  
Another pitfall is that the AKIN criteria require two creatinine levels 48 hours apart and presume that fluid resuscitation has occurred, whereas RIFLE does not. Many physicians don’t consider this when making an AKI or ARF diagnosis, again making it difficult to ensure that the clinical circumstances support the codes being assigned, says Kennedy.He encourages coders to read the criteria and query for clarification when the facts just don’t add up. 
  • Look for other lab results that may support AKI. Don’t be afraid to look for abnormal lab results, and query to determine their clinical significance, says Kennedy. In particular, the following lab results help differentiate ARF from AKI:
    • Elevated fractional excretion of sodium (less than one is prerenal; more than three is acute tubular necrosis)
    • Abnormal urinanalysis involving protein, blood, or urinary casts
    • Radiology reports showing dilated kidneys with obstruction or impaired perfusion of the renal cortex
    • Biomarkers, such as urine NGAL, KIM-1, or Cystatin C, once they become available
  • Ask physicians to link ARF with the underlying pathology. To assign the correct code within the 584.5–584.8 range, coders must be able to not only identify the specific lesion, but also know that the lesion is directly linked to the ARF, as specified in the provider’s documentation. Be aware that RACs and other government auditors may deny claims that don’t include explicit physician documentation of the link, says Kennedy. In particular, review Coding Clinic, second quarter 2003, p. 7, which states that coders should assign 584.9 (ARF, unspecified) when a patient is admitted in “acute renal failure secondary to lupus nephritis.”  
Editor’s note: For additional tips, subscribe to HCPro’s Briefings on Coding Compliance Strategies. Subscribers can find the article in the December issue of their newsletters.


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