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.
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.
In June CMS released the final ICD-10-PCS codes for FY2022, which begins October 1, 2021. We are giving you a sneak peek at the changes. HIA will have a full educational module on these changes available later this summer.
CMS released the IPPS proposed rule on 4/27/21 outlining the proposed changes to the Inpatient Prospective Payment System for FY2022, which begins October 1, 2021. Later this year, sometime in August, CMS will release the Final Rule. Currently CMS is reviewing responses to their proposed rule and will address them in the final rule.
A medical coding audit is a process that includes internal or external reviews of medical coding and billing accuracy, procedures or policies in place, and any other component that affects the medical record documentation. Medical coding audits…
Anticoagulants and antiplatelets are used for the prevention and treatment of blood clots that occur in blood vessels. Oftentimes, anticoagulants and antiplatelets are referred to as “blood thinners,” but they don’t actually thin the blood at all. These drugs slow down the body’s process of making clots. Their main function is to keep the patient’s blood from clotting or turning into solid clumps of cells. These drugs do this by interfering with either fibrin or platelets in the blood.
Carotid artery disease is a vague category that can incorporate many different carotid artery issues. Some physicians may feel that they are being clear the patient has plaque, stenosis, or occlusion of the artery, but in ICD-10-CM the specificity must be included in the documentation.
10 ICD-10 Codes for Superheroes. Superman: T78.2XXA Anaphylactic reaction; substance: kryptonite. Batman: F44.81 Dissociative identity disorder. Robin: F60.7 dependent personality. The Hulk: L30.4 Erythema intertrigo. Wonder Woman: T24.032A Burn of unspecified degree of left lower leg. Black Panther S93.401A Sprain…
Practices have not seen many revisions to the Evaluation and Management (E/M) office / outpatient visit guidelines in three decades – until now. As of January 1, there are new E/M coding guidelines. We’ll get to those in a bit, but first let’s look at why they changed.
Pseudoseizures are a form of non-epileptic seizure. These are difficult to diagnose and oftentimes extremely difficult for the patient to comprehend. The term “pseudoseizures” is an older term that is still used today to describe psychogenic nonepileptic seizures (PNES).
With the implementation of ICD-10-CM came different codes and coding rules for many diagnoses. One of these is the coding of bowel obstruction when the patient presents for this condition that is caused by another condition.
This is Part 5 of a five part series on the new 2021 CPT codes. For the remaining areas we will just briefly summarize the section. Due to the intricate nature of these sections in CPT, it is recommended that the coder read the entire section notes associated with the new codes.
This is Part 4 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes in the urinary, nervous, ocular and auditory systems. There are 2 new urinary/male reproductive system codes with no revisions or deletions; 3 new female reproductive codes with 2 deletions, 0 new with 4 deleted nervous system codes with 5 revisions; 5 new eye category III codes; and finally a 2 new auditory codes with one deletion.
This is Part 3 of a five part series on the new 2021 CPT codes. In this series we will explore the cardiovascular system CPT changes. There are 5 new cardiovascular CPT codes added with 0 deletions and 4 revisions.
This is Part 2 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes for FY2021 and include some examples to help the coder understand the new codes. There are 0 new musculoskeletal CPT codes added with 0 deletions and 2 major revisions along with an extensive update to arthroscopic loose body removal requirements. For the respiratory system, there were 2 new codes, one code deletion and no revisions.
This is Part 1 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes for FY2021 and include examples to help the coder understand the new codes. For 2021 in general, there were 199 new CPT codes added, 54 deleted and 69 revised.
In January, new CPT codes were released. There were 248 new CPT codes added, 71 deleted and 75 revised. Most of the surgery section changes were in the musculoskeletal and cardiovascular subsections. These included procedures such as skin grafting, breast biopsies, deep drug delivery systems, tricuspid valve repairs, aortic grafts and repair of iliac artery.
We have seen many updates and changes to COVID-19 (SARS-CoV-2) since the pandemic started. On January 1, 2021 we will see even more changes as outlined in this post. Also the CMS MS-DRG grouper will be updated to version 38.1 to accommodate the changes.
In the previous three parts of this four-part series, we discussed the new ICD-10-CM diagnosis code changes, ICD-10-PCS procedure code changes and FY2021 IPPS changes. In this last Part 4 of the series, we will review the NTAP procedure codes and reimbursement add-on payments for FY2021.
In the previous two parts of this four part series, we discussed the new ICD-10-CM diagnosis code changes and ICD-10-PC procedure code changes. In this session we will review the major IPPS changes for FY2021.
This is Part 2 of a 4 part series on the FY2021 ICD-10 Code and IPPS changes. In this part, the ICD-10-PCS procedure codes are presented. For FY2021 ICD-10-PCS there are 78,115 total codes (FY2020 total was 77,571); 556 new codes (734 new last year in FY2020)…
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)
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” 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.
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.
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.
Lately we have seen several cases where the endarterectomy was assigned along with the coronary artery bypass (CABG) procedure when being performed on the same vessel to facilitate the CABG. A coronary artery endarterectomy is not always performed during a CABG procedure, so when it is performed it becomes confusing as to whether to code it separately or not.
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.
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.
One common element in many value-based programs is risk adjustment using Hierarchical Condition Categories (HCCs) to create a Risk Adjustment Factor (RAF) score. This method ranks diagnoses into categories that represent conditions with similar cost patterns.
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.