Transcript HCPro Audioconference 5.23.07

5 Coding and Documentation
Challenges
A coder-physician dialogue
an HCPro audio conference presented on
October 20, 2010
James S. Kennedy, MD, CCS
and
Margi Brown, RHIA, CCS, CCS-P, CPC, CCDS
Acute Kidney Injury
2
Clinical Scenario
• An 80 yo lady is admitted from the nursing home with
fever, hypovolemia, and a urinary tract infection.
– Day 1
• Dx: Attending: Sepsis due to UTI, Renal Azotemia
• Creatinine 2.0, BUN 40 (baseline Cr = 1.0 mg/dl)
– Day 3
• Dx: Renal consult: Acute Kidney Failure with acute interstititial
nephritis likely due to acute pyelonephritis
• Creatinine 1.5, BUN 30; Blood culture + for E.coli.
– Day 5
• DC Summary Dx by the attending physician:
E.Coli sepsis due to UTI
Acute Kidney Injury, resolving
• Creatinine 1.3, BUN 15 (elevated 0.3 mg/dl from baseline)
3
How should the kidney function be coded?
Is query necessary?
• 584.9 – Acute Kidney Injury
• 584.8 – Acute Renal Failure associated with
other specified pathological lesion of the
kidney
– Acute Interstitial nephritis is a pathological lesion
• 593.9 – Unspecified disorder of the kidney
and ureter
– Acute renal disease
– Acute renal insufficiency
• 790.6 – Other abnormal blood chemistry
– Azotemia
4
What is “Acute Kidney Injury”?
• Acute Kidney Injury
– a common clinical syndrome
defined as a sudden onset of
reduced kidney function
manifested by increased serum
creatinine or a reduction in urine
output.
• It is NOT the underlying renal
pathology
– Currently a preferred term and
synonym for acute renal failure
or acute kidney failure.
• Some physicians may not agree
Resource: Srisawat N., Hoste, E., Kellum, JA.
Modern Classification of Acute Kidney
Injury.
Blood Purification 2010;29:300–307.
Available for free at:
• Acute Kidney Insufficiency
– The same definition as acute kidney
injury, yet the rise of creatinine or fall
of urine output fails to meet the acute
kidney injury criteria
• Azotemia
– a medical condition characterized by
abnormally high levels of nitrogencontaining compounds, such as urea
(BUN) , creatinine, various body
waste compounds, and other
nitrogen-rich compounds in the
blood.
• Uremia
– A term used to loosely describe the
illness accompanying kidney failure,
in particular the nitrogenous waste
products associated with the failure
of this organ
http://tinyurl.com/AKI-2010-Review
5
Instigating Causes
of Acute Kidney Injury
• Pre-renal
–
–
–
–
Hypovolemia
Impaired Cardiac Output
Shock
Bilateral renal artery
stenosis
• Post-renal
– Urinary obstruction
– Ureteral obstruction in a
patient with one kidney
• Renal
– Glomerular
• e.g. glomerulonephritis
– Tubulointerstitial
• e.g. tubulointerstitial
nephritis, acute tubular
necrosis
– Vascular
• e.g. renal vasculitis,
bilateral renal
embolism.
6
Renal Pathology Associated with
Acute Kidney Injury
• Ischemia
– focal tubular necrosis
at multiple points with
large skip areas in
between
– often accompanied by
rupture of basement
membranes and
occlusion of tubular
lumens by casts
• Toxins
– Tubular necrosis,
primarily in the
proximal tubules
• Certain toxins have
characteristic findings
ICD-9-CM Index to Diseases
Nephropathy
Toxic – 584.5 – Acute Renal
Failure with lesion of tubular
necrosis
Source: Kumar, Robbins and Cotran. Pathologic Basis of Disease, Professional Edition , 8th ed.:
7
Renal Pathology associated with
Acute Kidney Injury
• Acute Interstitial Nephritis
– rapid clinical onset
– Histology shows interstitial edema, often accompanied by leukocytic
infiltration of the interstitium and tubules, and focal tubular necrosis.
– Seen with acute pyelonephritis, transfusion reactions, and allergic
reactions to medications.
• Malignant Nephrosclerosis
– Occurs in accelerated and malignant hypertension
– Fibrinoid necrosis of the arterioles
• Thrombotic Microangiopathies
– Occurs with Disseminated Intravascular Coagulation (DIC), Thrombotic
Thrombocytopenic Purpura, and Hemolytic-Uremic Syndrome
– Patchy or diffuse cortical necrosis (described later) and subcapsular
petechiae
Source: Kumar, Robbins and Cotran. Pathologic Basis of Disease, Professional Edition , 8th ed.:
8
Can Acute Renal Failure and
ESRD co-exist?
• Question:
– What is the appropriate code assignment for a patient with
documented acute kidney failure and end stage renal disease
(ESRD) during the same admission? Is acute kidney failure an
acute exacerbation of chronic kidney failure?
• Answer:
– Acute kidney failure and chronic kidney failure are two separate
and distinct conditions.
• Acute renal failure has an abrupt onset and is potentially reversible.
Chronic kidney failure progresses slowly over time and can lead to
permanent kidney failure. The causes, symptoms, treatments, and
outcomes of acute and chronic are different.
• End-stage renal disease is when the kidneys permanently fail to work.
– If both acute and chronic kidney failure are clearly documented,
code both.
Coding Clinic, 3rd Quarter, 2010, page 15.
Clinical Criteria of
Acute Kidney Injury
•
Two prevailing definitions of AKI/ARF exist, as outlined in the following table
http://ccforum.com/content/11/2/R31 – AKIN;
http://ccforum.com/content/8/4/R204 - ADQIG
Note: AKIN criteria requires 2 creatinine levels 48 hours apart and presumes that fluid
resuscitation has occurred. Neither require that the patient receives dialysis.
Note: Most nephrologists equate “RISK” in RIFLE to be Acute Kidney Injury, even if it is
not labeled as such. Further clarification from these authors is forthcoming.
10
Other Laboratory Supporting
Acute Kidney Injury
• Elevated Fractional
Excretion of Sodium
– aka – FENa
– Calculation:
Urine Na x Plasma Cr X 100
Plasma Na x Urine Cr
– Interpretation
• Less than 1 – Prerenal
• Over 3 – Acute Tubular
Necrosis
• Abnormal Urinanalysis
– Protein
– Blood
– Casts
• Radiology
– Dilated kidneys showing
obstruction
– Impaired perfusion of the
renal cortex.
• Biomarkers
–
–
–
–
–
Not ready for prime time
Urine NGAL
KIM-1
Cystatin C
Interleukin-18
11
ICD-9-CM Index
• Injury
– kidney - see Injury, internal, kidney
• acute (nontraumatic) 584.9
•
Note that Acute Kidney Injury ONLY codes to 584.9, Acute Kidney
Failure, unspecified,
– It does NOT code to 584.5 through 584.8
• The title of 584.9, Acute Kidney Failure, unspecified is the only
indication in ICD-9-CM that acute kidney injury is equivalent to
acute renal failure or acute kidney failure, yet coders may not
assume this, given its listing in the Index to Diseases.
– Coding Clinic opinion is needed to determine if acute kidney injury
with a specified renal pathological lesion codes to 584.5 through
584.8.
• Otherwise, the physician must document “acute renal failure” or
“acute kidney failure” to qualify for these codes.
12
What code is assigned to the initials
“AKI”?
• Airplane sickness 994.6
• Akathisia, acathisia 781.0
– due to drugs 333.99
– neuroleptic-induced acute
333.99
AKI IS NOT IN THE
INDEX TO
DISEASES
• Akinesia algeria 352.6
• Akiyami 100.89
• Akureyri disease (epidemic
neuromyasthenia) 049.8
• Alacrima (congenital) 743.65
• Alactasia (hereditary) 271.3
• AKI can mean either
– Acute Kidney Injury
– Acute Kidney Insufficiency
• 3M’s encoder software
considers AKI to be Acute
Kidney Injury
– Coding Clinic 4th Q 2008, page
192-193 states
How should AKI be coded?
Answer: Assign code 584.9,
Acute renal failure, unspecified,
for a nontraumatic acute kidney
injury (AKI).
• Even so, given that AKI is not in
the Index to Diseases, it’s
always best that a physician
write the term out if it is to be
compliantly coded
13
What about
Acute Renal Failure?
• Failure, Renal
– acute 584.9
• with lesion of
– necrosis
» cortical (renal) 584.6
» medullary (renal) (papillary) 584.7
» tubular 584.5
– specified pathology NEC 584.8
ICD-9-CM Table
584 Acute kidney failure
Includes Acute renal failure
Excludes:
– following labor and delivery (669.3)
– posttraumatic (958.5)
– that complicating:
•
•
•
abortion (634-638 with .3, 639.3)
ectopic or molar pregnancy (639.3)
584.5 Acute kidney failure with
lesion of tubular necrosis
– Lower nephron nephrosis
– Renal failure with (acute) tubular
necrosis
– Tubular necrosis:
•
•
•
•
584.6 Acute kidney failure with
lesion of renal cortical necrosis
584.7 Acute kidney failure with
lesion of renal medullary
[papillary] necrosis
– Necrotizing renal papillitis
•
•
584.8 Acute kidney failure with
other specified pathological
lesion in kidney
584.9 Acute kidney failure,
unspecified
Acute kidney injury (nontraumatic)
NOS
acute
593.9 – Unspecified disorder of kidney and ureter (Not a CC at all)
Acute renal insufficiency or acute renal disease
790.6 – Other abnormal blood chemistry (Not a CC at all)
Azotemia
586 – Renal failure, unspecified – uremia (Not a CC; Level 2 in APR-DRG)
15
MS-DRG & APR-DRG
MCC/CC Classification
584 Acute kidney failure
• 584.5 Acute kidney failure with
lesion of tubular necrosis
• 584.6 Acute kidney failure with
lesion of renal cortical necrosis
• 584.7 Acute kidney failure with
lesion of renal medullary
[papillary] necrosis
• 584.8 Acute kidney failure with
other specified pathological
lesion in kidney
• 584.9 Acute kidney failure,
unspecified
Acute kidney injury
(nontraumatic)
← Major CC
APR SOI = 4
APR ROM = 4
← Major CC
APR SOI = 4
APR ROM = 3
← Major CC
APR SOI = 4
APR ROM = 3
← Major CC
APR SOI = 4
APR ROM = 3
← On October 1, 2010,
CMS changed 584.9
from a MCC to a CC
APR SOI = 4 (?)
APR ROM = 3 (?)
16
The meaning of the word “with”
• ICD-9-CM Official Guidelines for 2011 – New addition
– The word “with” should be interpreted to mean “associated
with” or “due to” when it appears in a code title, the
Alphabetic Index, or an instructional note in the Tabular
List.
– The word “with” in the alphabetic index is sequenced
immediately following the main term, not in alphabetical order.
• Faye Brown’s ICD-9-CM Coding Handbook
– Words such as “with” and “in” indicated that both elements in the
title must be present in the diagnostic or procedural statement.
– Although these terms do not necessarily indicate a cause-effect
relationship, they occur together much of the time and the
classification system indicates this relationship.
• Note – While Faye Brown is not official advice, it is written by Coding
Clinic and should reflect their positions.
17
The meaning of the word “with”
• Osteomyelitis (general)
(infective) (localized)
(neonatal) (purulent)
(pyogenic) (septic)
(staphylococcal)
(streptococcal) (suppurative)
(with periostitis) 730.2
– due to or associated with
• diabetes mellitus
250.8 [731.8]
• Coding Clinic, 1st Quarter,
2004, pages 14-15
– ICD-9-CM assumes a
relationship between
diabetes and osteomyelitis
when both conditions are
present, unless the
physician has indicated in
the medical record that the
acute osteomyelitis is
totally unrelated to the
diabetes.
Even though this Coding Clinic advice is very clear for osteomyelitis
associated with diabetes, some coders will not generalize this advice to
other conditions labeled in a similar manner.
18
584.5 Acute kidney failure with
lesion of tubular necrosis
• Acute tubular necrosis
(ATN) is defined by acute
kidney injury and tubular
damage in the absence of
significant glomerular or
vascular pathology.
– Tubular casts, red cells,
and protein may be seen in
the urinanalysis.
– If the offending agent is
removed, the kidneys
usually repair themselves.
ICD-9-CM Index
• Nephropathy
• Toxic – 584.5
• Vasomotor – 584.5
• Most common cause of
renal pathology causing
AKI
– Ischemic
• Shock, hypotension
– Toxic
•
•
•
•
•
•
•
•
•
Radiological contrast media
Aminoglycosides
Cephalosporins
Amphotericin
Anesthetic agents
Antiviral agents
Thiazides
Calcineurin inhibitors
Herbal medications
19
584.6 Acute kidney failure
with lesion of renal cortical necrosis
• Necrosis of the renal cortex,
usually due to hypoperfusion
– 2% of adult AKI
– 20% of pregnancy-related AKI
• Related conditions
– Pregnancy-related conditions
(more than 50% of cases)
•
•
•
•
Placental abruption
Infected abortion
Prolonged intrauterine fetal death
Severe eclampsia
– Neonatal conditions
•
•
•
•
Congenital heart disease
Fetal-maternal transfusion
Dehydration
Perinatal asphyxia
– Childhood conditions
• HUS
• Acute gastroenteritis with
dehydration
• Diagnosis
– Contrast-enhanced CT
scanning
• CT scanning with contrast are the
most sensitive imaging modality.
• Diagnostic features include absent
opacification of the renal cortex
and enhancement of subcapsular
and juxtamedullary areas and of
the medulla without excretion of
contrast medium.
– Renal scanning
• Diethylenetriamine pentaacetic
acid (DTPA) scan reveals
markedly diminished perfusion
with delayed or no function.
• Renal scan is the imaging
technique of choice to diagnose
renal cortical necrosis in
transplant kidneys or if contrastenhanced CT scanning are
unavailable.
20
584.7 Acute kidney failure with lesion
of renal medullary [papillary] necrosis
• Necrosis of the papilla
– Occurs with
cumulative toxicity
from analgesic
medication
• Tylenol
• Goody Powders
– Sickle Cell disease
– Acute pyelonephritis
– Diabetes mellitus
Photo Source: POLAND/Poznań
Source: http://tinyurl.com/3ysws6c
Photo reproduction governed by:
http://creativecommons.org/licenses/by-sa/2.5/deed.en
21
584.8 Acute kidney failure with other
specified pathological lesion in kidney
• Most of the codes of 580-583
would qualify as specified
pathological lesions.
Those that would not include:
– 580.9 Acute glomerulonephritis
with unspecified pathological
lesion in kidney
– 581.9 Nephrotic syndrome with
unspecified pathological lesion in
kidney
– 582.9 Chronic glomerulonephritis
with unspecified pathological
lesion in kidney
– 583.9 Nephritis & Nephropathy
with unspecified pathological
lesions
Category 583 includes "renal disease"
so stated, not specified as acute
or chronic but with stated
pathology or cause.
• 583.8 Nephritis and nephropathy,
not specified as acute or chronic
with other specified pathological
lesion in kidney
– 583.81 in diseases classified
elsewhere
– Code first underlying disease, as:
•
•
•
•
•
amyloidosis (277.30-277.39)
diabetes mellitus (249.4, 250.4)
gonococcal infection (098.19)
Goodpasture's syndrome (446.21)
systemic lupus erythematosus
(710.0)
• tuberculosis (016.0)
581.81 (e.g. diabetic nephrosis) and 583.81 (e.g. diabetic nephropathy)
would appear to qualify as a linking term to 584.8, Acute Renal Failure
with other specified renal pathology, if not for the following Coding Clinic
22
584.8 vs. 584.9
CC, 2nd Quarter, 2003, page 7
• Question: The patient is a 36-year-old female with a long-standing history
of systemic lupus erythematosus admitted in acute renal failure secondary to
the lupus nephritis. In this case, should the acute renal failure or lupus
nephritis be sequenced as principal diagnosis?
• Answer:
– Assign code 710.0, Systemic lupus erythematosus, as the principal
diagnosis.
• The physician's documented that the patient was admitted for lupus
nephritis.
– Code 584.9, Acute renal failure, unspecified
– Code 583.81, Nephritis and nephropathy, not specified as acute or
chronic in diseases classified elsewhere.
Note that 584.8 - Acute kidney failure with other specified pathological lesion in
kidney - was not recommended, even though 583.81 is coded as an “other” specified
pathology and a direct link between the acute renal failure and the lupus nephritis.
Coding Clinic needs to clarify when to use 584.8 or 548.9 in light of ICD-9-CM
conventions and the definition of the word “with” and “specified pathologic lesions”.
In the meantime, this Coding Clinic will likely be used by RACs in their audits.
Acute Kidney Injury
Summary
• Physician education is essential to identify acute
kidney injury
– Please use the academic articles provided
• For the most part, to code 584.5-584.8, physicians
must document “acute renal failure” instead of “acute
kidney injury”
– Physicians must cite acute kidney injury’s underlying
pathology (e.g. ATN – Interstitial nephritis – renal cortical
necrosis – toxic nephropathy) and, to be safe, link it to the
acute renal failure.
– Uncertain diagnoses cannot be coded unless documented
at the time of discharge.
• Contact Coding Clinic for official advice in how to code
acute renal failure “with” the specified pathological
lesions in 580-583.
24
Clinical Scenario
• An 80 y/o lady is admitted from the nursing home with fever,
hypovolemia, and a urinary tract infection.
– Day 1
• Dx: Attending: Sepsis due to UTI, Renal Azotemia
• Creatinine 2.0, BUN 40 (baseline Cr = 1.0 mg/dl)
– Day 3
• Dx: Renal consult: Acute Kidney Failure with acute interstititial
nephritis likely due to acute pyelonephritis
• Creatinine 1.5, BUN 30; Blood culture + for E.coli.
– Day 5
• DC Summary Dx by the attending physician:
E.Coli sepsis due to UTI
Acute Kidney Injury, resolving
• Creatinine 1.3, BUN 15 (elevated 0.3 mg/dl from baseline)
• Final codes: 038.42 + 995.91 + 599.0 + 584.9 + 580.89.
• Even though the consultant wrote “acute renal failure”, it conflicts with
acute kidney injury written by the attending.
• Pyelonephritis was “uncertain”, thus not coded.
25
Thank You
Questions?