Health Information Management

Q&A: Look for etiology when querying for renal failure

CDI Strategies, February 17, 2011

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Q: Since Acute Renal Failure (ARF) is no longer a MCC (as of October 1, 2010). I would like some input on how facilities have coped with the change. Do you just code ARF, or have you started querying physicians for more specific information such as documentation for acute tubular necrosis, lesion of renal cortical necrosis, renal medullary necrosis, and specified pathological lesion in kidney?

A: We revamped our query forms for acute kidney injury (AKI) to include questions regarding the etiology of AKI, however, the form does not list specific situations as we felt this would be seen to be leading the physicians toward documenting MCCs,” says Judi Bates RN, BSN, CCDS, CDI specialist at Lourdes Health System, in Camden, NJ.

“I always ask for the diagnosis with the underlying cause or condition,” says Robert S. Hodges, BSN, MSN, RN, Clinical Documentation Improvement Specialist at Aleda E. Lutz VAMC, in Saginaw, MI. “So essentially, nothing changed for me or the way I address the issue.”
Editor’s Note: This Q&A first appeared on the ACDIS Blog. It was adapted from an exchange in CDI Talk, the listserve for ACDIS members.

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