Renal Failure [Documentation Suggestions]
Describe clinical signs and symptoms (e.g., skin darkening, itching, muscle cramps, progressive rise in BUN, elevated urine protein, etc.).
Document work-up (e.g., kidney CT scan, kidney venogram or arteriogram, etc.).
Document treatment (e.g., IV erythropoietin, dialysis, etc.).
Note potential underlying cause, if known (e.g., diabetes, hypertension, trauma, ibuprofen use, etc.).
Specify whether acute or chronic failure. Avoid use of the term “insufficiency” in place of “failure.”For coding and billing purposes, these terms are not synonymous.
: "Reference Materials", Health Care Excel, Medicare Quality Improvement Organization, and contractor of the Centers for Medicare & Medicaid Services (downloaded from web site: