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.

Additional notes:



Source: "Reference Materials", Health Care Excel, Medicare Quality Improvement Organization, and contractor of the Centers for Medicare & Medicaid Services (downloaded from web site: 7/7/03)