Q&A: Evaluating abnormal renal function in the clinical record
Q: When abnormal renal function is documented without a clear diagnosis, what clinical indicators should coders review to determine whether a provider query is warranted?
A: When documentation reflects abnormal renal function but does not clearly identify the underlying diagnosis, coders should review the medical record for clinical indicators that support clarification of the patient's renal status and determine whether a provider query is appropriate.
Key clinical indicators to look for include:
- Trends in serum creatinine and estimated glomerular filtration rate (GFR) throughout the encounter
- Prior baseline renal function, if available
- A documented history of chronic kidney disease (CKD), including CKD stage
- Urine output trends and intake/output monitoring
- Renal-focused treatments such as intravenous fluids, Foley catheter placement, renal function monitoring, or nephrology consultation
- Pharmacy dosing adjustments for renally cleared medications, such as vancomycin
- Associated conditions that may contribute to renal dysfunction, including sepsis, diabetes mellitus, and hypertension
- Additional laboratory findings, vital signs, and provider documentation that may indicate acute or chronic kidney impairment
Take for example a patient that presented with an elevated creatinine level of 1.9 mg/dL, but without a documented baseline, it was unclear whether the finding represents an acute kidney injury, progression of chronic kidney disease (CKD), acute tubular necrosis, or renal dysfunction associated with another condition such as sepsis. Reviewing prior records may reveal a nephrology consultation documenting a history of CKD or other conditions along with baseline creatinine and GFR values, providing important context for the current encounter.
Coders should also evaluate evidence of clinical concern for renal dysfunction. Interventions such as strict intake and output monitoring, intravenous fluid administration, serial renal panels, nephrology consultation, and renal-based medication dosing adjustments may indicate that providers are actively assessing or treating impaired kidney function, even when a definitive diagnosis has not yet been documented.
Additional information regarding the patient's condition before admission can provide important insight as well. Documentation of poor oral intake, decreased urine output, poorly controlled diabetes, hypertension, or medication noncompliance may help explain the development or worsening of renal dysfunction.
A comprehensive evaluation of abnormal renal function requires more than identifying an elevated creatinine level. It involves a detailed review of laboratory trends, treatment interventions, historical records, and clinical documentation to fully understand the patient's renal status and support accurate clinical assessment. By reviewing these clinical indicators, coders can identify opportunities for compliant provider queries that help clarify the nature, cause, and severity of abnormal renal function, supporting accurate code assignment and complete clinical documentation.
Editor’s note: This question and answer were originally published in JustCoding, which adapted it from the HCPro webinar, “Strategic Querying: The Value of a Great Question,” presented by Sarah Matacale, BSN, RN, CCS, CCDS, a query education and compliance specialist for ACDIS and AHIMA.