Health Information Management

Q&A: Dealing with denials for ICD-9-CM code 584.9 due to lab values

JustCoding News: Inpatient, March 14, 2012

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QUESTION: Recently, reviewers have denied diagnostic code 584.9 (acute renal failure [ARF]) based on lab values. The diagnosis is well documented and treated by the attending physician, but reviewers are stating the lab values do not support the diagnosis of ARF.

The lab values (creatinine/blood urea nitrogen) went from normal to abnormal, and we found no definitive standards for lab parameters to meet the definition of ARF. Following coding guidelines for reporting secondary diagnoses, the ARF was clinically evaluated, the patient received therapeutic and diagnostic procedures, and there was an extended length of stay/increased nursing care. As coders, we feel it is inappropriate to question the physician’s clinical judgment, and reporting the ARF as a secondary diagnosis is correct. Based on the documentation in the record, is it appropriate to code the ARF?

ANSWER: From a strict coding standpoint, I tend to agree that you should assign the code if the treating physician clearly documented ARF in the medical record and he or she met the criteria of clinically evaluating and/or treating this condition during an admission per the Uniform Hospital Discharge Data Set definitions of an “other/additional diagnosis.”

But in saying that, I would like to explore this issue.

It is not up to a coder to debate clinical scenarios with the physician (e.g., whether the patient had a condition). Others have shared similar scenarios with me in the past, such as when the payer deems the single CC or MCC not supported clinically even though it is clearly documented in the medical record. This can be very frustrating for hospitals when their CC or MCC is not acknowledged as relevant or clinically supported. When payers do this, it negates the MS-DRG logic that the patient only needs one diagnosis designated as a CC (or MCC) to be assigned to that MS-DRG.

That said, it makes some sense for payers to explore patients with single CCs or MCCs. From their financial perspective, some scrutiny makes sense because it affects overall reimbursement. The documentation and clinical indicators in the medical record should clearly support reported diagnoses to justify code assignment. I am not sure whether your organization has a documentation improvement program, but I do see that there could be an opportunity for potential documentation improvement efforts to assist in these situations.

When it comes to clinical definitions of acute renal failure, the RIFLE criteria is a commonly used resource:

  • Risk: Increase in serum creatinine level X 1.5 or decrease in GFR by 25%, or UO <0.5 mL/kg/h for 6 hours – Cr rise of 0.3 mg in appropriate circumstance
  • Injury: Increase in serum creatinine level X 2.0 or decrease in GFR by 50%, or UO <0.5 mL/kg/h for 12 hours
  • Failure: Increase in serum creatinine level X 3.0, decrease in GFR by 75%, or serum creatinine level > 4 mg/dL; UO <0.3 mL/kg/h for 24 hours, or anuria for 12 hours
  • Loss: Persistent ARF, complete loss of function >4 wk
  • End-stage kidney disease: Loss of function >3 mos

As you can see, the criteria is not merely going from normal to abnormal, but depends also on other factors shown in the lab values.

Editor’s note: Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding at HCPro, Inc., in Danvers, MA, answered this question. E-mail questions to Managing Editor Doreen Bentley.

This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

Need expert coding advice? Submit your question to Managing Editor Doreen Bentley, CPC-A, and we’ll do our best to get an answer for you.

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