Acute Renal Failure Denial

We have received a denial for ARF in a 60 year old patient admitted for bradycardia. Creatinines were 1.76 day 1, 1.43 day 2, 1.36 day 3, and finally 1.30 on day 4. Our labs range of normal is 0.6 to 1.30 mg/dl.

 The reviewer has denied the secondary dx of ARF because there was no baseline creatinine. My assertion is that the final creatinine in the normal range is the baseline. Patients don't come to the lab to have a creatinine drawn because they might be admitted to the hospital the following week.

I feel the change in the creatinine from the admission value to the discharge value meets KDIGO criteria for acute renal failure. Your thoughts are appreciated, 

Michael Bushey, M.D.

Comments

  • If one takes 1.30 as baseline, you would need a Cr of 1.95 on admit to satisfy KDIGO.

  • I have also argued with an estimated baseline creatinine in the absence of CKD located in the KDIGO AKI Guideline, page 28. 

    https://kdigo.org/wp-content/uploads/2016/10/KDIGO-2012-AKI-Guideline-English.pdf

  • edited March 30

    I agree that this patient would meet AKI guidelines per KDIGO.

    AKI is defined as any of the following (Not Graded):

    Increase in SCr by X0.3 mg/dl (X26.5 lmol/l) within 48 hours; or

    Increase in SCr to X1.5 times baseline, which is known or presumed to have occurred within  the prior 7 days; or

    evanspx@sutterhealth.org      Why would one use the with in 7 days criteria for this case?   

  • Hey @hrboissonneault the "Increase in SCr by 0.3mg/dl within 48hours" can only be used prospectively.

    Based on the information the OP provided the patients creatinine never increased during the admission and there is no evidence of a 1.5x increase from baseline.

    I have a few tools I use for AKI denials and denials in general.

    First, I look to see if I have any historical data that would help. For instance from another recent admission or outpatient visit to see if I can reasonably establish a baseline in a patient without CKD, because as mentioned by a previous poster it is assumed in a patient without CKD that a creatinine will remain stable for months or even years.

    Next, I look to see if there was any documentation of a baseline that's different than what was drawn during the admission. So for the patient above, if the Doc wrote anywhere in the chart that the patient's baseline creatinine was 1.17 or less, then that would meet the 1.5x criteria for AKI.

    If no luck there, I review the chart for a CC that might have been documented but not coded. I have won several denials this way.

    Finally, if all else fails I try to write a compelling appeal demonstrating any and all treatment, workup, and medical decision making that occurred as a result of this diagnosis and cite OCG 1.A.19 noting that coding is based on documentation, not the criteria used to establish the diagnosis and that this diagnosis clearly meets UHDDS criteria for coding and reporting.

    Hope that helps OP!

  • The case does not meet KDIGO with admit Cr 1.76 and discharge Cr 1.30

    KDIGO states ‘increase in Cr level to greater than or equal to 1.5 baseline (historical or measured), which is known or presumed with the prior seven days”. We would take the discharge value of 1.30 as assumed baselines.


    1.30 x 1.5 = 1.95 and the admit Cr was les than 1.95


    P. Evans, RHIA, CCDS

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