Coding Tip: Acute Renal/Kidney Failure/Injury vs Dehydration as a Principal Diagnosis
Pat Maccariella‑Hafey
RHIA, CDIP, CCS, CCS‑P, CIRCC
Executive Director Of Education
AHIMA‑Approved ICD‑10‑CM/PCS Trainer and Ambassador
Patients being admitted for acute renal failure due to dehydration have been happening for many, many years now. Typically what happens is a patient gets dehydrated for one reason or another. Once dehydration sets in, it can quickly start to affect many body organs. One of these is the kidneys. This can lead to acute renal/kidney failure/injury.
Dehydration
Dehydration results from excessive water loss from body tissues. Etiologies include but are not limited to extensive vomiting, diarrhea, gastroenteritis, renal or adrenal disease, diabetes mellitus, diuretic therapy, or having an ileostomy or colostomy. Symptoms include diminished skin turgor or a “tenting” of the skin, dry oral mucosa and skin, a shrunken tongue, tachycardia, low central venous pressure, postural hypotension, and in severe cases, disorientation and shock. Lab tests that help diagnose dehydration are elevated BUN, elevated Hgb and hematocrit, elevated potassium and decreased sodium. Treatment is IV fluids and sodium, usually at a high IV rates 125cc/hr to 250cc/hr. However, the size of the patient will dictate how much fluid and what rate it is infused. So there is no hard and fast rule. Sometimes fluid boluses are given right away to address significant dehydration.
Dehydration is coded to E86.0, Dehydration, and results in DRGs:
641, Misc disorders of nutrition, metabolism, fluids/electrolytes w/o MCC, Weight 0.7519
640, Misc disorders of nutrition, metabolism, fluids/electrolytes w MCC, Weight 1.1902
Acute Kidney Failure/Injury
Acute renal/kidney failure or injury is a sudden, severe onset of inadequate kidney function. There are many causes of acute renal/kidney failure/injury, however, when due to dehydration, it is because there is decreased renal blood flow from lower blood pressure because of the dehydration. This starts causing functioning problems with the kidney. Symptoms include oliguria, edema resulting from salt and water overload, nausea and vomiting, lethargy from the toxic effects of the waste products building up, hydronephrosis and at times metabolic acidosis. BUN and creatinine will be significantly elevated. There are several types of criteria for acute kidney failure/injury and some hospitals compile their own.
Some well known clinical criteria for validating this diagnosis are:
- RIFLE (Risk of renal dysfunction, Injury to kidney, Failure or Loss of kidney function,
and End-stage kidney disease) - AKIN (Acute Kidney Injury Network stage)
- KDIGO (Kidney Disease: Improving Global Outcomes group)
Treatment involves treating the underlying cause, and if due to dehydration, that means treating the dehydration with fluids. Renal function (BUN, creatinine) would be followed and monitored along with fluid intake. Acute kidney failure/injury can be life threatening if severe as the kidneys can shut down.
Acute renal failure/injury is coded N17.9, acute kidney failure, unspecified and if PDX leads to these DRGs:
684, Renal failure w/o CC/MCC Weight 0.6198
683, Renal failure w CC Weight 0.919.
682, Renal failure w MCC Weight 1.4532
Past advice is now superseded
There is a very old Coding Clinic, Third Quarter 2002, pages 21-22 with two questions involving acute renal/kidney failure due to dehydration. In both questions, AHA advised to report the acute renal/kidney failure/injury code as the principal diagnosis. Coders have been following that advice since it was published. Until now.
In Coding Clinic First Quarter 2019 page 12, AHA is now stating that there is no rule that acute renal/kidney failure/injury should always be sequenced first in these situations. They now are stating the sequencing of either dehydration or acute renal/kidney failure/injury should be based on the reason for admission. If it cannot be determined, or is not clearly documented, the physician should be queried.
What is a coder to do?
This is now a dilemma. Best practice is for the coder to look at both conditions documented clinically and carefully, remembering that every patient is different. Review the admission order to see if the physician is indicating the exact reason for admission. Look at the ED record and observation record to see what was treated and resolved before true inpatient admission. Look at the clinical indicators to see if both of the diagnoses are solidly supported by the documentation. Is one condition documented more acutely than the other? For example, in looking at the serum creatinine, was the increase only 25% and creatinine at 1.9 which is not twice the patient’s baseline? Was BUN only slightly elevated from the patient’s baseline? Were IV fluid boluses immediately given and IV set at 175 cc/hr? This may indicate that the dehydration was more of an acute reason for admission than acute renal failure/injury. Then there is the question of true acute renal/kidney failure/injury clinical validation in the case.
CDI professionals will also have to be sure physicians are documenting clinical indicators that would support acute renal/kidney failure/injury rather than only kidney insufficiency, which is coded differently and affects DRG assignment. Also, medications can sometimes affect the BUN and creatinine and it may not be a true indication of acute renal/kidney failure/injury. The coder should not be shy about escalating a case to CDI or a physician adviser if either diagnosis does not seem to be clinically validated, as this is part of a coder’s responsibility.
As can be seen in the DRGs above, choosing one of these diagnoses over the other as PDX can impact reimbursement. Having an MCC code on the record can also change up the DRG assigned and reimbursement. And of course surgical procedures can further change the DRG. It will be critically important that coders know the clinical indicators that validate these diagnoses, treatments rendered, and also remember that every patient is different. There is not one “across the board” answer as to what diagnosis is PDX for every patient who is admitted with acute renal/kidney failure/injury and dehydration.
References
Coding Clinic, First Quarter, 2019, page 12
sciencedirect.com/science/article/pii/S0929664617304035
akinet.org/akinstudies.php
kdigo.org/wp-content/uploads/2017/04/KDIGO-AKI-GL-for-JSN_wm.pdf
The information contained in this post is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
Popular Posts
Part 14: Spinal Fusion Coding — Spinal Fusion Series Summary
We have finished with the step-by-step coding tidbits on coding of spinal fusions. If you were not able to catch Parts 1-13 of this series focused on spinal fusions, please visit hiacode.com/topics/series/spinal-fusion-coding/.
Part 13: Spinal Fusion Coding — Harvesting of Autograft for Spinal Fusion
In Part 12, we focused on intra-operative peripheral neuro monitoring used during spinal fusion surgery. In Part 13, we are going to focus on harvesting of autograft and is it coded. Remember in Part 6, we learned that autograft is bone from the patient.
Part 12: Spinal Fusion Coding — Intra-Operative Peripheral Neuro Monitoring
In Part 11, we focused on identifying the computer assisted navigation used during spinal fusion surgery. In Part 12, we are going to focus on intra-operative peripheral neuro monitoring.
Part 11: Spinal Fusion Coding — Computer Assisted Navigation
In Part 10, we focused on identifying whether or not hardware from a previous spinal fusion is coded. In Part 11, we are going to discuss computer assisted navigation.
Part 10: Spinal Fusion Coding — Removing Hardware from Previous Fusion
In Part 9, we focused on identifying if decompression was also performed and if so, on which body part. In Part 10, we are going to focus on identifying if hardware was removed from a previous fusion site.
Subscribe to our weekly newsletter
Latest News
Part 14: Spinal Fusion Coding — Spinal Fusion Series Summary
We have finished with the step-by-step coding tidbits on coding of spinal fusions. If you were not able to catch Parts 1-13 of this series focused on spinal fusions, please visit hiacode.com/topics/series/spinal-fusion-coding/.
Part 13: Spinal Fusion Coding — Harvesting of Autograft for Spinal Fusion
In Part 12, we focused on intra-operative peripheral neuro monitoring used during spinal fusion surgery. In Part 13, we are going to focus on harvesting of autograft and is it coded. Remember in Part 6, we learned that autograft is bone from the patient.
Part 12: Spinal Fusion Coding — Intra-Operative Peripheral Neuro Monitoring
In Part 11, we focused on identifying the computer assisted navigation used during spinal fusion surgery. In Part 12, we are going to focus on intra-operative peripheral neuro monitoring.
Part 11: Spinal Fusion Coding — Computer Assisted Navigation
In Part 10, we focused on identifying whether or not hardware from a previous spinal fusion is coded. In Part 11, we are going to discuss computer assisted navigation.
Part 10: Spinal Fusion Coding — Removing Hardware from Previous Fusion
In Part 9, we focused on identifying if decompression was also performed and if so, on which body part. In Part 10, we are going to focus on identifying if hardware was removed from a previous fusion site.
Part 9: Spinal Fusion Coding — Was A Decompression Done During Spinal Fusion?
In Part 8, we focused on identifying if a discectomy was performed, and if so, if it was a partial or a total discectomy. In Part 9, we are going to focus on identifying if a decompression was performed, and if so, was it of the spinal cord, spinal nerves or both?
Part 8: Spinal Fusion Coding — Discectomy During Spinal Fusion
In Part 7, we focused on identifying any instrumentation that may be used during a spinal fusion. In Part 8, we are going to focus on identifying if a discectomy is performed and if this is an excision or a resection of the disc.
Part 7: Spinal Fusion Coding — Identify Any Instrumentation or Device Used
In Part 6, we focused on identifying the type of bone graft product used for the spinal fusion. In Part 7, we are going to focus on identifying any instrumentation or device used.
Part 6: Spinal Fusion Coding — Identify the Type of Bone Graft Used for Fusion
In Part 5, we focused on identifying the approach being used for the spinal fusion. In Part 6, we are going to focus on identifying the type of bone graft used for the spinal fusion.
Part 5: Spinal Fusion Coding — Identifying the Approach Being Used for Fusion
In Part 4, we focused on determining the spinal column being fused. In Part 5, we are going to focus on identifying what approach is being used to complete the spinal fusion (anterior, posterior or both).
HIA Launches Buddy Up Program for New Hires
This past year, HIA implemented “Buddy Up,” a program designed to help the new hire have a smooth transition into their new HIA roles with the assistance of a “buddy.” What is a Buddy? The Buddy is simply a peer who can guide the new hire in order to make them feel more comfortable. We are very proud of this program and have many success stories that we would like to share. Take a look at the wonderful feedback we have received below.
Part 4: Spinal Fusion Coding — Identifying the Column Being Fused
In Part 3, we focused on determining the level of the fusion(s) and how to determine the number of vertebrae fused. In Part 4, we are going to focus on identifying which column is being fused (anterior, posterior or both).
Part 3: Spinal Fusion Coding — Determine the Level(s) or Region of Fusion and Number of Vertebrae Fused
In Part 1, we learned the diagnoses associated with the need for spinal fusions, and in Part 2 the need to identify if the fusion is an initial or refusion of the vertebrae. In Part 3, we are going to focus on determining the level(s) of fusion, as well as the number of vertebrae fused.
Part 2: Spinal Fusion Coding — Initial Fusion or Refusion
In Part 2, we are going to look at the differences between initial fusion and a refusion. In ICD-9, there were specific codes to show if the fusion was an initial fusion, or if it was a refusion. In ICD-10-PCS, initial fusions and refusion procedures are coded to the same root operation “fusion.”
Part 1: Spinal Fusion Coding — Diagnoses Responsible
This is Part 1 of a 14 part series focusing on education for spinal fusions. Spinal fusion coding is a tough job for coders. There are so many diseases/disorders that result in the need for spinal fusion, and even more choices in reporting the ICD-10-PCS codes.
What’s the Best Defense? A Good Offense
The official definition from the Centers for Medicare & Medicaid Services (CMS) states that a Medicare overpayment is a payment that exceeds amounts properly payable under Medicare statutes and regulations. When Medicare identifies an overpayment, the amount becomes a debt you owe the Federal government.
Query Tip: Writing a Query Question – Simple and Concise is the Key
The question asked in a physician query may be the most important element of the document. Query questions need to be as simple and concise as possible. The physician should have no doubt what the coder is asking.
Coding Tip: Coding Complications of Transplanted Organs
Coding complications of transplanted organs has always been a coding dilemma. With the implementation of ICD-10-CM that didn’t change. However, coders have multiple directives to help in determining what a complication of the transplant is vs. non-transplant conditions and diseases.
Find Your Routine: Take Advantage of Educational Opportunities
We interviewed our most productive coders, reviewers and members of our education team, asking them what steps they take to find a rhythm that works for them. This week, we talked with Beth Martilik, MA, RHIA, CDIP, CCS, Assistant Director of Education, about the steps she takes to find her routine.
Coding Tip: Atrial Fibrillation
With the implementation of ICD-10-CM came more codes for reporting many different conditions and diseases, and atrial fibrillation is one of those. For many years there was only one code available for reporting this condition, even when the physician further specified the type of atrial fibrillation that the patient had. In ICD-10-CM, there are four codes to report atrial fibrillation.
Coder Q&A with Pat Macc: Mucoid Casts and Mucus Plugs
We have a case where the physician removes mucoid casts found during bronchoscopy. We have also seen mucus plugs removed during bronchoscopy. The MD performs bronchial washings then removes a large amount of tenacious and thick mucoid casts via bronchoscopy. Is this coded drainage, extirpation or excision? What body part is used?
Query Tip: How to Be More Efficient
The key to making the query process more efficient is to look for words or documentation while reviewing the record that may signal a potential query opportunity and to note the finding at that time. By the time a coder reaches the end of a record, documentation may have been found to eliminate the need for the query.
Coder Q&A with Pat Macc: Metastatic Cancer
Question: This patient is noted to have “Lymphangitic carcinomatosis of lungs with mediastinal lymph nodes.” How would I code the diagnosis? Would I code metastatic cancer to the lung (C78.01) or metastatic cancer to the lymph nodes (C77.1)?
Coder Q&A with Pat Macc: Collapse of an Endograft
This would be considered a “mechanical” complication of the stent graft since the MD states it is a fracture of the endograft and it is folded over on itself. I would change T82.898A TO T82.598A for Other mechanical complication of other cardiac and vascular devices and implants, initial encounter. I did not use “displacement” because the surgeon did not state that the graft was displaced, only that it collapsed upon itself causing obstruction.
Find Your Routine: Be Flexible, Not Frustrated
We interviewed our most productive coders and reviewers, asking them what steps they take to find a rhythm that works for them. This week, we talked with Valerie Abney, CDIP, RHIT, CCS, about the steps she takes to find her routine.
Coding Tip: Periprosthetic Fracture Reporting and Sequencing
Osteoporosis alone is responsible for over a million fractures every year. Stress fractures are not as common but they do occur. There are more than 1 million total joint replacements in the U.S. each year, so there was a need to create codes for injuries that occur around or near the prosthesis. These are called “periprosthetic” fractures.
OIG Takes Notice of Coding Errors
Back in April, the Office of the Inspector General (OIG) published a report detailing its findings from a review of two groups of high-risk diagnosis codes, acute stroke and major depressive disorder. The objective was to determine whether selected diagnosis codes submitted to the Centers for Medicare and Medicaid Services for use in CMS’s risk adjustment program complied with Federal requirements.
Coder Q&A with Pat Macc: Coding for Newborn
There seems to be differences of opinions on the issue of a 40w0day gestation Can you clarify if P08.21 should be assigned for 40w0day infant or if it would not be assigned unless the infant’s gestation age was 40w1day or greater?
Query Tip: When to Query for Sepsis
Coders may find situations where a patient is documented as meeting SIRS or sepsis criteria, or has some clinical indicators reflective of possible sepsis, but the physician never documents sepsis as a diagnosis. Should the coder always query for sepsis in these instances?