Part 5: Reasons for AKI Denials and Prevention | AKI Series
Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
Part 5 of this series is the final part. In this tip, we will look at some of the common reasons given for acute kidney injury (AKI) denials and what coders can do to help prevent these.
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. 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”
- “The treatment provided did not reflect resources needed for the diagnosis of AKI”
- “Diagnosis is acknowledged to be in the medical record from the physician but don’t think this is a valid diagnosis”
- “Documentation does not support the diagnosis of AKI as defined by the RIFLE criteria”
- “Documentation does not support the diagnosis of AKI as defined by the AKIN criteria”
- “Documentation does not support the diagnosis of AKI as defined by the KDIGO criteria”
- “The clinical indicators within the medical record can be explained by the patient’s dehydration and do not justify a diagnosis of acute kidney injury”
Can the coders prevent acute kidney injury (AKI) denials for clinical validity?
Absolutely! As you can see, in the examples above the majority of the denials for the diagnosis of AKI are due to lack of clear documentation of the diagnosis, or the lack of clinical indicators to support the diagnosis of AKI within the medical record. Remember, even if coded based on the physician documentation, if there are no clinical indicators present to support the diagnosis, there is a high chance of denial. When this occurs, it impacts the entire facility. Denials are expensive. Payment must be returned and/or not received. The facility must spend time to review the records that are denied and all this just adds up.
What can coders do to help prevent costly denials on AKI?
- Educate providers and CDI on what is needed in the documentation such as a good history and physical if AKI is present at time of admission and/or in the hospital course to capture the severity of illness, and also any signs and symptoms related to the diagnosis of AKI. The hospital course should include a detailed summary of the finding, the workup done as well as treatment needed to improve the acute injury.
- Any clinical signs and symptoms or other indicators that are related to AKI should be linked to the diagnosis in the medical record. If they are not linked, it is easy for the payer to relate them to another condition such as dehydration.
- Documentation should be consistent and complete…if not, a query is necessary for clarification.
- Collaboration between coders, CDI and physicians to ensure that the documentation clearly describes the condition of AKI.
- Facilities should have an escalation policy for CDI and/or coders to send records that lack clinical support of AKI prior to finalizing the record.
- Coders, CDI and physicians should be aware of the different AKI classifications/criteria used.
- If there are contracts with certain payers on what classification/criteria will be used for validation of AKI, the coders, CDI and physicians should be aware of this. If they are not aware then there may surely be lacking documentation in the record.
- QUERY at the time of coding prior to billing/finalization.
- NEVER depend on the denial letter to list all the clinical indicators in the record. ALWAYS complete a full review of the medical record to be sure that there are no other clinical findings to help support the diagnosis that was reported. Oftentimes, only a superficial or minimal review of the record may lead to a claim denial.
- Consider having a second level review to determine if there is clinical validity within the record to support the diagnosis of AKI before billing/finalizing.
- Appeal letters should include ALL of the supporting documentation in the record for AKI and any references that help to support reporting this diagnosis.
- When writing an appeal letter, be sure and state that you realize that there are differences of opinion on the criteria used for the diagnosis of AKI, but none have been mandated for use.
Remember, even if coded based on the physician documentation, if there are lacking clinical indicators to support the diagnosis, there is a high chance of denials. When this occurs, it impacts the entire facility.
References
cdc.gov/mmwr/volumes/67/wr/mm6710a2.htm
emedicine.medscape.com/article/1925597
americannursetoday.com/acute-kidney-injury
academic.oup.com/ck/article/6/1/8/468698
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
Happy Coding!
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.
New ICD Codes and IPPS Changes for FY2021 (ICD-10-CM Diagnoses changes) – Part 1
This is Part 1 of a 4 part series on the FY2021 changes to ICD-10 and the IPPS. In this part, we discuss some of the new ICD-10-CM diagnosis changes. Here is the breakdown: 72,616 total ICD-10-CM codes for FY2021; 490 new codes (2020 had 273 new codes); 58 deleted codes (2020 had 21 deleted codes); 47 revised codes (2020 had 30 revised codes)
Coding Tip: Reporting “Flash” Pulmonary Edema
Acute pulmonary edema is the rapid accumulation of fluid within the tissue and space around the air sacs of the lung (lung interstitium). When this fluid collects in the air sacs in the lungs it is difficult to breathe. Acute pulmonary edema occurs suddenly and is life threatening.
Client S: $556 increase/record reviewed
“Client S” is a small, not-for-profit, 40 bed micro-hospital in the Southeast. HIA performed a 65-record review this year for Client S and found an opportunity with 15 of them. 9 had an increased reimbursement with a total of $43,228 found.
Coding Tip: Glasgow Coma Scale Coding OCG Update for FY2021
The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale may also be used to assess the status of the central nervous system for other non-trauma conditions, such as monitoring patients in the intensive care unit regardless of medical condition.
Coding Tip: Cardiac Arrest and Cardiac Shock
In the past, there had been an Excludes1 note at I46.- Cardiac arrest that excluded R57.0, Cardiac shock. HIA had also received a letter from AHA on a case in the past that had stated that only I46.- Cardiac arrest would be coded if both were documented. In addition, the Third Quarter Coding Clinic page 26 had a similar case that asked if both could be coded, and AHA had instructed that only I46.9, cardiac arrest, cause unspecified would be coded if both were documented and that the CDC would be looking at possible revision to the Excludes1 note.
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New ICD Codes and IPPS Changes for FY2021 (ICD-10-CM Diagnoses changes) – Part 1
This is Part 1 of a 4 part series on the FY2021 changes to ICD-10 and the IPPS. In this part, we discuss some of the new ICD-10-CM diagnosis changes. Here is the breakdown: 72,616 total ICD-10-CM codes for FY2021; 490 new codes (2020 had 273 new codes); 58 deleted codes (2020 had 21 deleted codes); 47 revised codes (2020 had 30 revised codes)
Coding Tip: Reporting “Flash” Pulmonary Edema
Acute pulmonary edema is the rapid accumulation of fluid within the tissue and space around the air sacs of the lung (lung interstitium). When this fluid collects in the air sacs in the lungs it is difficult to breathe. Acute pulmonary edema occurs suddenly and is life threatening.
Client S: $556 increase/record reviewed
“Client S” is a small, not-for-profit, 40 bed micro-hospital in the Southeast. HIA performed a 65-record review this year for Client S and found an opportunity with 15 of them. 9 had an increased reimbursement with a total of $43,228 found.
Coding Tip: Glasgow Coma Scale Coding OCG Update for FY2021
The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale may also be used to assess the status of the central nervous system for other non-trauma conditions, such as monitoring patients in the intensive care unit regardless of medical condition.
Coding Tip: Cardiac Arrest and Cardiac Shock
In the past, there had been an Excludes1 note at I46.- Cardiac arrest that excluded R57.0, Cardiac shock. HIA had also received a letter from AHA on a case in the past that had stated that only I46.- Cardiac arrest would be coded if both were documented. In addition, the Third Quarter Coding Clinic page 26 had a similar case that asked if both could be coded, and AHA had instructed that only I46.9, cardiac arrest, cause unspecified would be coded if both were documented and that the CDC would be looking at possible revision to the Excludes1 note.
Client X: Let’s Talk Numbers
A higher CMI corresponds to increased consumption of resources and increased cost of patient care, resulting in increased reimbursement to the facility from government and private payers, like CMS. We know that documentation directly impacts coding.
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Assign code Z20.828, “Contact with and (suspected) exposure to other viral communicable diseases” for all patients who are tested for COVID-19 and the results are negative, regardless of symptoms, no symptoms, exposure or not as we are in a pandemic.
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The Centers for Medicare & Medicaid Services (CMS) announced new procedure codes for treatments of COVID-19 – effective as of August 1, 2020. Among the new codes are Section X New Technology codes for the introduction or infusion of therapeutics including Remdesivir, Sarilumab, Tocilizumab, transfusion of convalescent plasma, as well as introduction of any other or new therapeutic substances for the treatment of COVID-19.
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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.
Coding Tip: Z Code Reporting for COVID-19
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).
Part 3: Clinical Indicators for Acute Kidney Injury/Failure | AKI Series
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FY2021 Proposed Rule and Code Changes Highlights
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.
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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.
Part 1: What is Acute Kidney Injury (AKI)? | AKI Series
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.
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Coding Tip: Reporting Vaping in ICD-10-CM | Effective on 4/1/2020
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.
Telehealth and the Coronavirus
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
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.
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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.
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This is part one of a three part series in which we address how coders can better interact with Clinical Documentation Integrity (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.
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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.
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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.
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