AKI

After listening to the wonderful HCPro audioconference today that hightlighted the new changes regarding AKI as an MCC, I have the need to ask...
Does your facility accept AKI to mean Acute renal injury, Acute renal failure as one and the same. Seems there is a need to clarify the difference regarding function (AKI) and pathology (ARF), according to Dr Kennedy. That they are 2 separate conditions in the coding world. I know it will be a challenge to change physician habits as far as what is an easy thing to write, (AKI). And now we want them to specify the underlying condition that led to AKI and BTW...Don't write AKI anymore.
Any thoughts are appreciated.

Comments

  • edited April 2016
    AKI (non traumatic) and ARF have the same code 584.9 as of October 2009. Not sure why Dr. Kennedy is saying this now. Check the date of the audioconference. If old, before Oct 2009, AKI was considered traumatic and had a 866.XX injury code.

  • edited April 2016
    Well, technically, non-traumatic acute kidney injury and acute renal failure both code to 584.9. The conditions are differentiated in the RIFLE criteria, with injury being less severe than failure. I know when I see an acute change in renal function I query for the level of severity based on RIFLE criteria and an underlying cause.

    Robert

    Robert S. Hodges, BSN, MSN, RN
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
     
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov
     


  • We have discussed this with our renal docs - at our facility AKI and ARF are synonymous - it is even listed on our abbreviation list.
    The only time we query to clarify is if someone (we have one PA) documents acute kidney insufficiency and then AKI.


  • What do you do when your physicians document chronic renal insufficiency stage 4??
  • edited April 2016
    I educate them that "insufficiency" in the literature is a minor
    condition and normally acute. If they document it as chronic I ask them
    to clarify it according to National Kidney Foundation guidelines. But
    then I'm a little obsessive compulsive too.



    Robert



    Robert S. Hodges, BSN, MSN, RN

    Clinical Documentation Improvement Specialist

    Aleda E. Lutz VAMC

    Mail Code 136

    1500 Weiss Street

    Saginaw MI 48602



    P: 989-497-2500 x13101

    F: 989-321-4912

    E: Robert.Hodges2@va.gov



    "The difference between the right word and the almost right word is the
    difference between lightning and the lightning bug." Samuel "Mark Twain"
    Clemens. The difference is the Lord not Mark Twain.




  • edited April 2016
    This is very helpful !! Thanks Charlene

    -
  • edited April 2016
    This is great! I would like to have this added to the tools and forms on ACDIS website. Thank you so much for sharing!




  • edited April 2016
    I have some additional information (in some powerpoint slides) that is too large to attach here. If anyone wants this material you can email me direct at lspryszak@hcpro.com. Put "AKI" in the subject line and I'll send it out.

    AKI and ARF, unspecified have the same code - 584.9, which is a CC as we all know.

    The only renal failure conditions that qualify for MCC status are the following:

    Renal failure (OR AKI) due to or associated with:
    - ATN
    - medullary necrosis
    - cortical necrosis
    - with other specified pathological lesion

    Also note that we need to get both components - the ARF or AKI plus the etiology (listed above) to get the right code.

    It should be considered standard practice to always ask what the cause of the ARF/AKI is. That way we're delivering a consistent message to the providers and can't be accused of only querying when it results in a higher-weighted DRG.
  • edited April 2016
    Indeed, VERY Nice!!

    I also did a blog post that talked about ATN you may find useful:
    http://blogs.hcpro.com/acdis/2010/12/resources-to-help-cdi-with-atn-confusion/

    Don

  • edited April 2016
    I did not get the post below (dated 07-26-11 @ 9:05AM) that mentions an information sheet re ATN. Could someone repost the attachment?
    Thanks,

    Sharon

  • Ha! Good question Paul.
    We don’t, or I wouldn’t recommend it at least. It needs to be spelled out as it could be acute kidney injury or acute kidney insufficiency.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Friday, January 17, 2014 2:46 PM
    To: Kathryn Good
    Subject: [cdi_talk] AKI

    Some controversy here:

    HOW do you code the ABBREVIATION "AKI"???

    Any responses appreciated.

    Paul Evans, RHIA, CCDS
    ---
    CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.

    You are receiving this message as a member of CDI Talk as: kathryn.good@nahealth.com If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12649561.a6bbaf3538c19e934e5136fbd051a6b1@hcprotalk.com
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  • AKI is an abbreviation with multiple meanings...IMO, the term requires a query. However, my coding mgr is adamant this codes to 584.9 and no query is required. I disagree, but welcome opinions.

    Yes - one should check Bun, Cr, GFR, so forth - however, coding from only an abbreviation has some risks...

    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.637.9002
    Fax:  415.600.1325
    Ofc:  415.600.3739
    evanspx@sutterhealth.org




  • I think it comes down to your facility...I thought there was a specific coding clinic about aki -injury vs insufficiency but I can't find it.

    http://forums.hcpro.com/forum/messageview.cfm?catid=14&threadid=9974

    A previous place I worked viewed it like this: AKI means acute kidney injury UNLESS someone states insufficiency as well- then it should be queried for clarification.

    Ann Donnelly,RN,BSN,CCDS

    On Jan 17, 2014, at 5:05 PM, CDI Talk wrote:

    > I'm with you Paul ;-)
    >
    > Katy Good, RN, BSN, CCDS, CCS
    > Clinical Documentation Program Coordinator
    > AHIMA Approved ICD-10CM/PCS Trainer
    > Flagstaff Medical Center
    > Kathryn.Good@nahealth.com
    > Cell: 928.814.9404
    >
    >
    > -----Original Message-----
    > From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    > Sent: Friday, January 17, 2014 2:55 PM
    > To: Kathryn Good
    > Subject: RE: [cdi_talk] AKI
    >
    > AKI is an abbreviation with multiple meanings...IMO, the term requires a query. However, my coding mgr is adamant this codes to 584.9 and no query is required. I disagree, but welcome opinions.
    >
    > Yes - one should check Bun, Cr, GFR, so forth - however, coding from only an abbreviation has some risks...
    >
    > Paul Evans, RHIA, CCS, CCS-P, CCDS
    >
    > Manager, Regional Clinical Documentation & Coding Integrity Sutter West Bay
    > 633 Folsom St., 7th Floor, Office 7-044 San Francisco, CA 94107
    > Cell: 415.637.9002
    > Fax: 415.600.1325
    > Ofc: 415.600.3739
    > evanspx@sutterhealth.org
    >
    >
    >
    >
    > -----Original Message-----
    > From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    > Sent: Friday, January 17, 2014 03:50 PM
    > To: Evans, Paul
    > Subject: RE: [cdi_talk] AKI
    >
    > Ha! Good question Paul.
    > We don
  • edited April 2016
    I think you have to be careful of the context in which AKI appears. Most of the time, we code it as ARF (acute renal failure/kidney injury), but if there is any question with labs, etc., we clarify the abbreviation.

    Linda Haynes, RHIT, CCDS
    Manager, CDI
    Legacy Health
    lhaynes@lhs.org

  • edited April 2016
    Hi Paul!

    I would code the AKI as 584.9 because of the C.Clinic -3rd Qrtr. 2011- AKI, diabetic Nephropahty and CKD, stage III clarification. The 2nd paragraph under the answer documents: "The correct coding is code 584.9, Acute renal failure , unspecified , for the diagnosis of AKI. With AKI included on your approved Med. Staff abbreviation list, I think you are covered in coding AKI to 584.9. Of course, clinical indicators should always be met.

    Jolene File,RHIT,CCS,CPC-H,CCDS
    Documentation Improvement Specialist-Coder
    Hays Medical Center
    jolene.file@haysmed.com

  • Hey Jeff, since the CR was trending down after the bolus of fluids, it looks more like dehydration.

  • edited April 2016
    Yes, Jeff, this classifies as AKI. Despite the fact that it is within the normal limits for the age group, the change in creatinine within the time parameters defined and treatment given make it AKI.

    Thanks,
    -Jane
    p 303-603-9581
    c 303-249-3521

  • I am not a Nephrologist, but those are huge changes in Cr….Are you using current KDIGO criteria? Pertinent question would be how the changes in Cr day-to-day. I’d cite the KDIGO criteria in any rebuttal. I assume you have that criteria.

    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.412.9421

    evanspx@sutterhealth.org

    [cid:image001.jpg@01D105B0.28790DA0]

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, October 13, 2015 12:02 PM
    To: Evans, Paul
    Subject: [cdi_talk] AKI


  • I found the KDIGO criteria on line but what I found seems to be more geared toward RRT and CRRT.
    Humana states that the KDIGO criteria can only be applied once patient is euvolemic such that creatinine is not continuing to actively decrease on IV fluids or oral rehydration thus negating typical pre renal causes of creatinine elevation.

    Theresa Crosslin RN CM
    Cookeville Regional Medical Center
    931-783-2078
    TCrosslin@crmchealth.org

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, October 13, 2015 2:11 PM
    To: Theresa Crosslin
    Subject: RE:[cdi_talk] AKI

    I am not a Nephrologist, but those are huge changes in Cr….Are you using current KDIGO criteria? Pertinent question would be how the changes in Cr day-to-day. I’d cite the KDIGO criteria in any rebuttal. I assume you have that criteria.

    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.412.9421

    evanspx@sutterhealth.org

    [cid:image001.jpg@01D105C2.DD66A120]

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, October 13, 2015 12:02 PM
    To: Evans, Paul
    Subject: [cdi_talk] AKI


    We are seeing coding denials from Humana for Acute Renal Failure. The rational they are giving is that the diagnosis of Acute Kidney Failure will only be considered after achieving an adequate status of hydration and after excluding urinary obstruction. Also criteria for Acute Kidney Failure will not apply if patient is on diuretic.
    On admission the BUN was 78, Cr 4.6, Na 124 This did improve with IV fluid.
    Day of D/C Cr 0.8, BUN 12

    So I wondering if others are seeing this type of denial and if so what are you doing about it?
    Theresa Crosslin RN CM
    Cookeville Regional Medical Center
    931-783-2078
    TCrosslin@crmchealth.org





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  • Thank you!
    Kim Williams, RN
    Clinical Documentation Specialist
    Revenue Management Department
    (252) 535-8154
    (252) 535-8937 fax

    [cid:image002.jpg@01D105D4.4F8559C0]




    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, October 13, 2015 3:34 PM
    To: Williams, Kim
    Subject: RE:[cdi_talk] AKI

  • Given you have cited the change in the Cr from 4.6 down to 0.8, I don’t see how any person would not consider this some form of acute renal Failure. I don’t recall the GFR you may have sited at the time of D/C, but this is also not a ‘new’ diagnosis of CKD.
    I’d be interested to see how others in our profession feel, particularly someone that may have experience taking care of CRF patients on dialysis unit, or with strong background in renal topics.

    It would be helpful to cite the step-wise change in Cr from day to day – everything I have been taught about ARF supports the condition when the abrupt changes cited in KDIGO occur.

    I don’t find the exclusions that Humana is citing either, but I have not taken time to read the KDIGO before I reply today –

    To my knowledge, 3 main forms of ARF have been recognized for decades


    · Pre

    · Renal

    · Post


    The fact a pt may indeed have a pre-renal form of ARF does not mean the condition is present or supported IMO. But, again, I am not an MD.

    Paul

    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.412.9421

  • Sorry – typo: I meant to state:

    The fact a pt may indeed have a pre-renal form of ARF does not mean the condition is NOT present or supported IMO. But, again, I am not an MD.


    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.412.9421

    evanspx@sutterhealth.org

  • edited April 2016
    A bit unrelated, but I had several denials for ATN recently citing that we didn’t perform a renal biopsy-WHAT! ?
    My advice- appeal and use evidence. I believe they count on organizations throwing in the towel and in that case, it is an easy win for them.
    Good luck!
    Kerry

    Kerry Seekircher, RN, BS, CCDS, CDIP
    Clinical Documentation Program Manager
    Northern Westchester Hospital
    400 East Main Street
    Mount Kisco, NY 10549
    Email: kseekircher@nwhc.net
    Phone: 914-666-1243
    Fax: 914-666-1013

  • I agree 100% with Kerry…I’d appeal this. Also would appeal if told a Dx of ATN must be supported by Biopsy…who made us this rule?????. Rarely does our staff perform a renal Biopsy with an exception being for pts post – renal transplant that are in ARF.

    Colleagues: I urge us all to appeal IF the denial does not seem valid…many of you have shared ‘reasons’ for denials from 3rd parties that are nothing more than fishing expeditions. If the denial is valid, so be it, learn and go on. But, if not, consider an appeal.


    [cid:image002.png@01D105C3.03797C70]


    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.412.9421

    evanspx@sutterhealth.org

    [cid:image001.jpg@01D105C2.974634D0]

  • I, too, have had an inordinate number of denials for acute renal failure from Humana, including requirements for biopsy. They also say incredibly stupid things like, “AKIN criteria require that volume status be addressed prior to RIFLE criteria,” which of course merges two completely different sets of criteria. I wrote one appeal where the creatinine continued to worsen after hydration and they said it was evidence the patient didn’t have AKI. Another patient had a history of only CKD 3 and a baseline creatinine of 1.4, and was admitted with a creatinine of 5.64 and they said it wasn’t AKI because the patient improved, although at discharge her creatinine was still 2.1x her baseline and GFR was down 69%.

    I appeal almost every time and they just continue to deny. One huge problem for us with Humana is that they are their own judge, jury and executioner, so the same people who originally denied are the ones who handle the appeal. And they just repeat the same tired arguments without even addressing anything I’ve said. I think their function is to exhaust us into submission.

    Renee

    Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
    Director, Clinical Documentation
    Tanner Health System
  • edited April 2016
    Does it help to have your appeal signed off by a physician? Are yours, Renee?
    Has anyone spoken to a nephrologist (or Dr. Pinson for that matter) regarding this?

    Thanks,
    -Jane
    p 303-603-9581
    c 303-249-3521

  • It is just, in mind, not acceptable that a 3rd party would deny the diagnosis that has been clearly documented and meets a consensus medical community definition, citing the most recent medical research available, with criteria published internationally. This is not COMPLIANT with HIPAA, which is a Federal Mandate. I wonder how an Administrative Law Judge would rule?



    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.412.9421

    evanspx@sutterhealth.org



  • I wonder if any of our Board Members and/or physician ACDIS members could be of some type of assistance as this issue seems common to many of us? I recall that doctors Kennedy, Huff, and Pinson, among others have endorsed the same criteria for forms of ARF, and the various 3rd parties denying the diagnosis seem out-of-step with clinical guidelines and HIPAA and Official Coding Guidelines – these guidelines are the basis for claims, and should be followed.

    Paul

    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.412.9421

    evanspx@sutterhealth.org

    [cid:image001.jpg@01D1065C.75326590]

  • They tried to pull that with us. We cited both the rifle and kidgo criteria. We won.
    Kathy

    Kathleen Benson RN, BSN, CCDS
    Supervisor, Clinical Documentation Integrity
    UWHealth University of Wisconsin Hospital
    Office Location: University Crossing, 749 University Row, Suite 200
    Mailing Location: 600 Highland Avenue, Mail Code 9920
    Madison, WI 53792-9475
    608-516-5638
    kbenson@uwhealth.org
    [cid:image002.png@01D10671.9AE33E30]

  • They will try anything to deny, it just keeps getting more and more ridiculous!!

    Kathleen Benson RN, BSN, CCDS
    Supervisor, Clinical Documentation Integrity
    UWHealth University of Wisconsin Hospital
    Office Location: University Crossing, 749 University Row, Suite 200
    Mailing Location: 600 Highland Avenue, Mail Code 9920
    Madison, WI 53792-9475
    608-516-5638
    kbenson@uwhealth.org
    [cid:image003.png@01D1067C.55AABFE0]



  • It IS a game w/ some of these 3rd parties…they simply want to send us these ridiculous denials and hope we don’t have time or skill to respond. Some of them seem to have no training or knowledge about our profession(s). They certainly do not respect HIPAA, and in my view, this is almost criminal?


    When they are this far off course, they should be challenged. It is pertinent to note the some of the RAC audit firms have lost contracts because the audit findings were flawed.

    PE

    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.412.9421

    evanspx@sutterhealth.org

  • edited April 2016
    I have been studying this trying to figure out what the rationale is from Humana. They do site in the denial that the dx of Acute Renal Failure can only be considered after achieving an adequate status of hydration.

    I did find in Up-To-Date where AKIN had proposed that “The dx criteria should be applied only after volume status has been optimized”

    But in the modifications to the RIFLE and AKIN made by KDIGO makes no mention of this so did they remove this when they proposed their definition of Acute Renal Failure?

    Sorry I don’t mean to beat this to death but the coder has done I appeal and it has been denied and we have several other cases.

    Theresa Crosslin RN CM
    Cookeville Regional Medical Center
    931-783-2078
    TCrosslin@crmchealth.org

  • States have insurance commissioners that complaints can be taken to. Is there anything on a national level?


    Kim Williams, RN
    Clinical Documentation Specialist
    Revenue Management Department
    (252) 535-8154
    (252) 535-8937 fax

    [cid:image004.jpg@01D10694.60A13880]




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