AKI / ARF Denials (Not clinically supported)

edited May 2016 in CDI Talk Archive
We've been getting several denials for ARF/AKI that are not clinically supported by changes in Cr as cited by the auditor (cases also did not meet with UOP).

Does anyone have a written policy (for coders) to address this -- ie, guidance to not code if there is not clinical support in the record? Any other ideas on how to address (in addition to physician education)?
I am wondering if this might be an acceptable approach -- our coders struggle with this. They can clearly see that the clinical support is not there, but there is strong documentation trend and discussion of hydration to address the issue.

Don

Donald A. Butler, RN, BSN
Manager, Clinical Documentation
PCMH, Greenville NC
dbutler@pcmh.com




Comments

  • edited May 2016
    We also run into this not only with AKI/ARF but ABLA (minimal drop in
    H&H and no blood transfusions). Any guidance would be greatly
    appreciated.

    Gina Spatafore, RN
    Clinical Documentation Integrity Specialist
    Waterbury Hospital
    203 573 7647


  • edited May 2016
    This is one of the many reasons why ARF/AKI will become a CC after Oct 1
    (more than likely), we have the same problem with BC denying ARF,
    depending on which auditor is reviewing which facility. The NY auditor
    uses the RIFLE criteria, he uses this criteria irregardless if the
    providers documents why the patient won't meet criteria ......... we
    appeal these and generally they are approved.
    The PA auditor prefers the AKIN criteria .......... not as many denials,
    but or coding staff have the issue of taking anything documented by the
    provider ........ so we will clarify with the provider if we feel it
    doesn't meet criteria ............. it is such a time consuming process
    ............... this is what we as a facility came up with:
    Acute Renal Failure:
    VS
    Acute Renal Insufficiency:
    Trend Creatine through stay; if creatine level is elevated on admission
    and returns to baseline with in 24 hrs, they have insufficiency secondary
    to condition IE: dehydration, stricture, etc….
    Acute Renal Failure:
    Creatine increase of 0.5 over baseline, for greater than 24hrs
    And
    Treatment with IVF greater than 100cc/hr, or documentation of why rate is
    lower IE: CHF, etc
    And
    Diagnosis to support acute renal failure IE; dehydration, sepsis, poisons,
    BPH, etc

    Thank You,
    Susan Tiffany RN, CCDS
    Supervisor Clinical Documentation Program
    Guthrie Healthcare System

    "Twenty years from now you will be more disappointed by the things you
    didn't do than by the ones you did do. So throw off the bowlines. Sail
    away from safe harbor.Catch the trade winds in your sails. Explore. Dream.
    Discover." Mark Twain







  • edited May 2016
    I know I have seen this, what is the RIFLE criteria?



    Patsy Fowler RN, MSN, CCDS

    Certified Clinical Documentation Specialist

    Marion Regional Medical Center

    PO Box 1150

    Marion, SC 29571

    Office 843-431-2044

    Cell 843-431-2863

    Fax 843-431-2475




  • edited May 2016
    Briefly for just the first 2 levels (there are both Cr and UOP as well as GFR standards to define each stage).
    Google AKI RIFLE and you should find some very good clinical articles.

    Risk 1.5 x baseline Cr (50% rise)
    Injury 2.0 x baseline Cr (100% rise) (or for a baseline Cr of 4, any rise of 0.5)
    Failure
    Loss
    ESRD

    Depending on the overall clinical picture, we consider query at the Risk level, and don't hesitate at the Injury level.

    AKIN (AKI Network) is similar, ie based on Cr changes, but presupposes adequate fluid resuscitation/hydration before looking at net Cr shifts to support the diagnosis, which is more complicated for the CDI.

    Don


  • edited May 2016
    This is beautiful Susan. Dumb question what is UO? Whom/what is your
    source?


    Kelley Walrath
    Documentation Specialist Coordinator
    BSN - CCDS
    352-671-2589 or x8426






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  • We've been getting denials for ARF but they don't bother to tell us why they're denying it. In my appeal letters, I reiterate the fact that there is no gold standard, despite the increasing use of RIFLE, and I will find and cite research articles that either disparage the use of a single standard or that suggest another standard. If the pt meets either the creatinine or the urine output standard of AKIN, and there is treatment/additional monitoring ordered, I will use that. Our lead nephrologist is committed to the 0.3 mg change standard for stage I AKI and he has trained our hospitalists to follow that, so I have to go along and make the documentation as strong as I can while the pt is here, and later if and when we get denied.

    As far as coders not coding what isn't supported in the record, our coders apparently were instructed to code whatever the physician writes, whether it's clinically supported or not. Then it became my job to try to make the data fit the diagnosis or get the diagnosis changed. That is a very, very hard job. I have been pushing very hard for our coders to be allowed to leave off a code if I feel it is prime to be challenged and lost on appeal. So now if they ask me about a questionable diagnosis and we agree that it's extremely weak, they will leave it off.

    Renee

    Linda Renee Brown, RN, CCRN, CCDS
    Clinical Documentation Specialist
    Arizona Heart Hospital
  • edited May 2016
    Source:
    1. Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P, and the ADQI
    workgroup: Acute renal failure – definition, outcome measures, animal
    models, fluid therapy and information technology needs: the Second
    International Consensus Conference of the Acute Dialysis Quality
    Initiative (ADQI) Group.
    Crit Care 2004, 8:R204-R212. PubMed Abstract | BioMed Central Full Text |
    PubMed Central Full Text

    urine output (UO)


    Thank You,
    Susan Tiffany RN, CCDS
    Supervisor Clinical Documentation Program
    Guthrie Healthcare System
    email: tiffany_susan@guthrie.org
    "Twenty years from now you will be more disappointed by the things you
    didn't do than by the ones you did do. So throw off the bowlines. Sail
    away from safe harbor.Catch the trade winds in your sails. Explore. Dream.
    Discover." Mark Twain







  • edited May 2016
    Many thanks to you all. This is a great learning tool for someone new to CDI like me.

    Theresa Woods, RN, MSN
    Jennings American Legion Hospital
    1634 Elton Road
    Jennings, La 70546
    Phone: 337-616-7297
    Fax: 337-616-7096
    twoods@jalh.com

  • edited May 2016
    Sounds like you are using the AKI Network criteria? that requires
    normal volume status / adequate fluid resuscitation?

    Don


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