A 64-year-old female with diabetes presents with nausea, edema, and elevated serum creatinine; discharge diagnoses include acute renal failure and diabetes. What is the CDI query opportunity?

• A. Does the patient have hypertension?
• B. Was there a history of kidney stones?
• C. Is there evidence of diabetic nephropathy?
• D. Should pancreatitis be coded as a comorbidity?

Answer: (A)

The key idea here is that hypertension often coexists with diabetes and kidney disease and is frequently underdocumented, yet it changes the patient’s risk profile and how the encounter is coded. In a 64-year-old with diabetes presenting with edema and elevated creatinine, the presence of hypertension on admission would be a meaningful comorbidity to capture. Documenting hypertension supports a fuller picture of why renal function might be compromised and how the patient’s health status affects prognosis and resource use, which in turn influences coded severity and risk adjustment.

While diabetic nephropathy could be relevant, you would need explicit documentation of diabetic-related kidney disease to code that condition. The other options—history of kidney stones or pancreatitis—don’t align with the presenting information and are not as impactful for the current documentation, so they’re less appropriate as CDI query targets in this scenario.