Reasons for Acute Kidney Injury Denials and Prevention

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. There are three main criteria/classifications used to diagnose AKI. Below are the common classifications used to help explain what some of the denial examples are referring to:

• 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)

When looking at these different classifications for AKI, and the criteria that is being used, it’s evident that the majority of the issues for denials depend on which classification is being used by the physician, and which by the patient’s insurance carrier. There are no specific classification or criteria mandated for use in diagnosing AKI, so oftentimes the one used by the physician and the insurance provider don’t match.

This makes it difficult for coders as well as CDI, physicians and facilities. Coders, CDI and physicians should be aware of any specific coding and documentation guidelines that have been agreed upon with an insurance company or payer. Some contracts will specify which AKI classification they will be using to validate a reported diagnosis of AKI. If there is a contract stating which classification they will be using to validate the diagnosis of AKI, then that is the one that must be met for reporting purposes. It is evident by the reason for denials (listed below) that this is not being followed. Coding and or Health Information Management (HIM) should be involved and aware of anything in a contract that pertains to coding and documentation requirements of health care records. The language used in contracts for some payers on reporting the diagnosis of AKI is relevant to being able to appeal a denial.

Are AKI denials the coder’s fault? Not usually! The majority of these denials are clinical denials. A clinical denial audit is when the payer is questioning whether or not the physician’s diagnosis of AKI is clinically supported. The rest are usually due to conflicting documentation amongst multiple physicians documenting the diagnosis of AKI (such as injury, insufficiency, specific cause or possible condition not documented at discharge) and no query sent for clarification. Coders should be querying whenever conflicting documentation of a diagnosis is in the record.

Examples of denial reasons:

• “The diagnosis of ATN was not found in the medical record”
• “The query was noncompliant”
• “There were no documented signs or symptoms that would have been consistent with the diagnosis of AKI. Only a slight increase in creatinine documented. Without additional signs and symptoms, or other laboratory proof or treatment the diagnosis is not supported”
• “Significant resources were not used in the management of the diagnosis”
• “A query was warranted in the situation but not found”
• “Lack of clinical indicators documented in the medical record”
• and many more...

To learn more denial reasons and what coders can do, purchase our Acute Kidney Injury eBook.

More AKI Blogs

• What is Acute Kidney Injury? 
• Acute Kidney Injury Specificity Coding and Sequencing 
• Clinical Indicators for Acute Kidney Injury
• Is Documentation Present to Report Acute Kidney Injury?

Authored by Kim Boy, RHIT, CDIP, CCS, CCS-P

References
cdc.gov/mmwr/volumes/67/wr/mm6710a2.htm
emedicine.medscape.com/article/1925597
americannursetoday.com/acute-kidney-injury
kidney.org/atoz/content/AcuteKidneyInjury#
mayoclinic.org/diseases-conditions/kidney-failure/symptoms-causes/syc-20369048
uofmhealth.org/health-library/aa115361
cjasn.asnjournals.org/content/1/6/1314
ncbi.nlm.nih.gov/pmc/articles/PMC5094385/
ccforum.biomedcentral.com/articles/10.1186/cc13977
fortherecordmag.com/archives/021510p29.shtml
forums.acdis.org/discussion/167/aki-arf-denials-not-clinically-supported
acdis.org/articles/guest-post-understanding-common-denial-rationale-aki-and-atn
icd10monitor.com/meeting-criteria-foraki-sepsis
bok.ahima.org/doc?oid=302541#.XelmsIWJKUK

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.