Part 3: Clinical Indicators for Acute Kidney Injury/Failure | AKI Series
Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
In the first parts of this series we looked at definitions of AKI/ARF, causes, coding and sequencing. In Part 3, we will look at what clinical indicators would possibly be present to support the diagnosis of AKI/ARF.
Common Clinical Indicators for Acute Kidney Injury/Failure:
- Decreased urine production-less than 0.5 mL per kg per hour for more than 6 hours
- Abdominal pain
- Metal taste in mouth
- Increased BUN
- Increased serum creatinine level-increased in greater or equal to 0.3 mg per dL or greater than or equal to 1.5 to twice the patient’s baseline
- Increased potassium
- Metabolic acidosis
- Abnormal GFR
- Chest pain/pressure
Common Clinical Indicators for Acute Tubular Necrosis:
As we learned in the other parts of this series, acute tubular necrosis (ATN) is the most common cause of SEVERE acute renal failure, more so than acute cortical necrosis or medullary necrosis. In addition to the clinical indicators above, the following would be considered for a diagnosis of ATN:
- Prolonged reduced renal blood flow (ischemic ATN)
- Exposures to nephrotoxins and medications such as gentamycin, vancomycin, cyclosporine, tacrolimus, ace inhibitors, ARBS, cisplatin
- Oliguric or on-oliguric
- May require dialysis
- Rhabdomyolysis, hemoglobinuria, aminoglycosides in toxic ATN
- Sepsis, cardiogenic shock, hypovolemia, hypotension, vasoconstriction and postoperative status in ischemic ATN
- Hypoperfusion causing cell injury in ischemic ATN
- Acute decrease in GFR from tubular epithelial cell death and obstruction from casts and debris in the tubule lumen accompanied by a sudden increase in creatinine and BUN
Common Treatments for AKI/ARF including ATN:
- Fluid resuscitation
- Correction of electrolyte imbalances
- Avoidance of nephrotoxic medications/contrast media
- Dialysis if serious
- Treatment of the underlying condition that is causing
- Optimizing cardiovascular function
Three Main Criteria Used for Validation of AKI/ARF:
- RIFLE Classification—Risk, Injury, Failure, Loss and End-stage kidney disease. Established and published in 2004. Created with primary goal to develop a consensus and have evidence-based guidelines for the treatment and prevention of AKI. (See criteria reference below)
- AKIN Classification—Acute Kidney Injury Network. Established and published in 2007. This is a modified version of the RIFLE criteria. This was established in order to increase the sensitivity and specificity of the diagnosis of AKI. AKIN advised that acute renal failure be changed to acute kidney injury to represent the full spectrum of renal injury (mild to severe). (See criteria reference below)
- KDIGO Classification—Kidney Disease Improving Global Outcomes. Released in 2012 for use and is a build off of the RIFLE and AKIN criteria already being used. This criteria reserved the baseline creatinine that was established in RIFLE and a small increase in creatinine from AKIN. This is thought to give KDIGO greater sensitivity than RIFLE or AKIN. (See criteria reference below)
All three of the criteria listed above are comparable and excellent for use in diagnosing AKI. Coders should know which criteria their facility is using for diagnosing AKI so that they can be sure that the diagnosis given by the physician is clinically validated. There is no one criteria that is mandatory for use.
One of the most challenging areas that coders face today is knowing when a query is necessary. Coders see diagnoses that are documented by the physician in the medical record, and they want to be able to report the code for the diagnosis. However coders know they must clinically validate diagnoses and if they are not able to, query or get CDI or a physician liaison involved.
There is an OCG stating: “The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”
Does this mean coders may report any condition documented within a medical record?
No, of course not. All coders have seen copy/paste in medical records and problem lists that are brought in from previous admissions. When reporting a diagnosis, the condition must meet the reporting guidelines either for selection of PDX or as an additional SDX. The statement in the OCG above doesn’t mean that there doesn’t have to be clinical indicators for a disease present at all, only that the physician is not limited to a specific set of clinical criteria he can use to make a diagnosis. There are many “established” criteria for many diseases and AKI is no different. As above, there are three for AKI at this time.
What makes this so hard for coders is that it is difficult to question a physician’s documentation. When conflicting documentation within the record is present, that is much easier because coders are just asking for clarification. If a coder asks a physician “does this patient really have AKI/ATN?”, this could be a bad situation with a very negative outcome on the query. It is better to ask the physician what criteria were used to make the diagnosis of AKI or involve CDI or a physician liaison for help with these. Physician education is needed, and if coders don’t query, then the facilities and physicians will not know that there is a documentation issue. Physician’s should be aware and/or part of the decision on which criteria will be used for diagnosing a certain condition.
Be on the lookout for Part 4 of this series. We will be looking at what documentation is needed to report AKI, and see some examples of when a query is needed.
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
Why are so many AKI records being denied? It’s hard to give one answer for why so many AKI records are being denied lately, but most appear to be due to the multiple sets of criteria available for use in determining if a patient has AKI, as well as physician documentation. As stated in Part 3 of this series, there are three main criteria/classifications used to diagnose AKI.
In previous parts of this series we looked at the definitions of AKI/ARF, causes, coding and sequencing, and the common clinical indicators that patients present with that are diagnosed with this condition. In Part 4, we will look at the documentation that should be present to report the diagnosis without fear of denial, as well as when a query is needed to clarify the diagnosis.
If the facility does a COVID-19 test, and test is negative, do I need a diagnosis code. The answer is yes, you will report a Z-code. The Z-code depends on the record documentation and circumstances of testing. For any patient receiving a COVID-19 test, if negative, there MUST e a Z-code to describe why the test was taken. (Test negative for COVID-19 and MD does not override negative results).
The FY2021 IPPS Proposed Rule is out and here are some highlights from it regarding ICD-10 Code proposals. We will know if these changes are permanent after the public comment period is over on July 10, 2020 and CMS prepares the Final Rule, usually out by August 1.
As discussed in Part 1 of this series, AKI/ARF is a common diagnosis that coders see daily. In Part 2, we are going to focus on the different types/specificity of AKI/ARF. We’ll learn what they mean, as well as how to code the diagnosis.
This is part 1 in a series focused on coding of acute kidney injury (AKI) and/or acute renal failure (ARF). AKI/ARF is reported often, but is also one of the most common diagnosis found in denials.
With the proliferation of COVID-19 cases, we thought we would put together a quick reference listing of some of the common scenarios that coders have asked about. As with all coding, coders should follow Official Guidelines for Coding and Reporting and the COVD-19 Frequently Asked Questions document by the AHA.
Effective March 1, Medicare will pay physicians for telehealth services at the same rate as in-person visits for all diagnoses, not just services related to COVID-19. This great for providers whose patients are reluctant to visit the office.
The biggest reasons why some hospital systems are moving to single path coding is to eliminate duplicative processes and to optimize productivity. In addition, costs are reduced when only one coder “touches” the record and completes both types of coding.
Effective with 4/1/2020 discharges, ICD-10-CM code U07.0 is used to report vaping -related disorders. ICD-10-CM code U07.0 (vaping related disorder) should be used when documentation supports that the patient has a lung-related disorder from vaping. This code is found in the new ICD-10-CM Chapter 22. U07.0 will be in listed in the ICD-10-CM manual under a new section: Provisional assignment of new disease of uncertain etiology or emergency use.
The US government and public-health officials are urging consumers to utilize telemedicine for remote treatment, fill prescriptions and get medical attention during the new coronavirus pandemic. The goal is to keep people with symptoms at home and to practice social distancing if their condition doesn’t warrant more intensive hospital care.
Coronavirus: Tips for working from home. Companies around the world have told their employees to stay home and work remotely. Whether you’re a new to this concept or a work from home veteran, here’s some tips to staying productive from our #HIAfamily.
This is the final part of a three part series in which we address how coders can better interact with Clinical Documentation Improvement (CDI) professionals. In this part, we provide an actual example of an effective communication response to CDI.
This is part two of a three part series in which we address how coders can better interact with Clinical Documentation Improvement (CDI) professionals. In this part, we discuss mismatches and how to best go about resolving them. In part three we will provide a case example of best practice interaction.
This is part one of a three part series in which we address how coders can better interact with Clinical Documentation Improvement (CDI) professionals. Many times these departments are separate and the remote environment makes it difficult to interact efficiently between the two departments. In part one, we will discuss the history and objectives of CDI so the coder has a better understanding of CDI’s role.
One reason that coders should report chronic conditions (including history and status codes) on outpatient records is the HCC’s—Hierarchical Condition Categories. The quick and easy explanation of what HCC’s are is each HCC is mapped to certain ICD-10-CM codes or code ranges. HCC coding is designed to estimate future health care costs for patients.
For Part 5 of this 5-part series, we will look at Chapter 4 within ICD-10-CM—E00-E89—Endocrine, Nutritional, and Metabolic Diseases. There is no possible way to include every guideline or coding reference for this chapter, but here are some of the most common issues.
For Part 4 of this 5-part series, we will look at Chapter 10 within ICD-10-CM—J00-J99—Diseases of the Respiratory System. There is no possible way to include every guideline or coding reference for this chapter, but here are some of the most common issues.
For Part 3 of this 5 part series, we will look at Chapter 9 within ICD-10-CM—I00-I99—Diseases of the Circulatory System. This chapter contains so many of the everyday diagnoses that we code such as hypertension, heart disease and stroke.
For Part 2 of this 5-part series, we will look at Chapter 1 within ICD-10-CM—A00-B99—Certain Infectious and Parasitic Diseases. There is no possible way to include every guideline or coding reference for this chapter, but here are some of the most common issues.
For Part 1 of this 5-part series, we will look at Chapter 21 within ICD-10-CM—Z00-Z99—Factors influencing health status and contact with health services. There is no possible way to include every guideline or coding reference for this chapter, but I’ll do my best to touch on some off the most common issues.
The HIM world has been buzzing recently with discussion of “Social Determinants of Health” and coded data. What does this mean for coders and the HIM field?
In response to the recent occurrences of vaping related disorders and in consultation with the World Health Organization (WHO) Framework Convention on Tobacco Control, the WHO Family of International Classifications (WHOFIC) Network Classification and Statistics Advisory Committee (CSAC) was convened to discuss a diagnosis code for vaping related illness for immediate use.
We’re finally at the #1 most common DRG with recommendations by HIA for 2019. Just to recap, HIA reviewed over 50,000 inpatient records in 2019. Most have probably already guessed what the correct DRG would be with the most recommendations. There are just some diagnoses and DRG’s that will always be a thorn in the side for coders. #1 DRG with the most recommendations during HIA reviews : DRG 871—Septicemia or severe sepsis w/o mechanical ventilation >96 hours with MCC
We’re now at the second most common DRG with recommendations by HIA for 2019. Just to recap, HIA reviewed over 50,000 inpatient records in 2019. We are counting down to # 1. #2 DRG with the most recommendations during HIA reviews: DRG 872—Septicemia or severe sepsis w/o mechanical ventilation >96 hours w/o MCC.
In 2019, HIA reviewed over 50,000 inpatient records. Wow! That is a lot of records. Even with this large number of records, the DRG’s with recommendations are still the ones that coders typically see during audits. #3 DRG 190—Chronic obstructive pulmonary disease with MCC.
In 2019, HIA reviewed over 50,000 inpatient records. Wow! That is a lot of records. Even with this large number of records, the DRG’s with recommendations are still the ones that coders typically see during audits. #4 is DRG 193—Simple pneumonia & pleurisy with MCC.
In 2019, HIA reviewed over 50,000 inpatient records. Wow! That is a lot of records. Even with this large number of records, the DRG’s with recommendations are still the ones that coders typically see during audits. #5 DRG with the most recommendations during HIA reviews : DRG 853—Infectious & Parasitic diseases with O.R. procedure with MCC
Pivotal moments in the Health Information Management field include the implementation of ICD-10, CPT Coding Changes, Acute care changes, profee changes, recovery audit contractor implementation, new ransomware challenges, Meaningful use and much more.