Date Posted: Thursday,
February 34, 2022
In the first article of this series, we present an H&P of a medical record that was downgraded by the payer based on a denial of acute kidney injury or AKI that was added to the claim. The H&P was one of the very few places that AKI was documented; however, it was picked up by the coder because it was in fact part of the documentation.
AKI did not meet clinical criteria. Per KDIGO guidelines, AKI is defined as any of the following:
- 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
- Urine volume o0.5 ml/kg/h for 6 hours.
The keyword to remember is "baseline." This becomes especially relevant when the patient has CKD, as in the case presented herein. Having CKD does not negate KDIGO criteria and AKI should only be documented when one of the above criteria is met.
The provider should always document baseline, if known. If it is not documented, the payer generally uses an imputed baseline of the lowest serum creatinine obtained, which often is not in the hospital’s favor.
Even though the ED record and H&P had AKI documented, the patient was seen in consultation by cardiology and nephrology, where not only was the baseline documented to be 2.0, but the diagnosis of AKI was not even entertained.
This provides an opportunity for what I call "Reverse CDI." Instead of querying or coding to optimize reimbursement, query for clarity, severity, and education opportunities. A query might address the hospitalist this way:
"Dear Dr. ____: Your patient was admitted with a SCr of 2.0 in the setting of CKD. AKI was documented in the H&P; however, Dr. ____ from nephrology documented SCr 2.0 as the baseline. Per KDIGO, AKI is defined as ____ (insert criteria). Could you please clarify if AKI has been ruled out or if it remains a valid diagnosis for this encounter?"
CC: Weight gain, Dyspnea
HPI: 68 yo M w/ extensive PMHX comes in with 15-pound weight gain, after his cardiologist advised him to come in for AKI and CHF mgmt.; plan for IV diuretics. Failed out pt trial of oral diuretics and titration of meds. Weight had been down as low as 225 pounds (goal wt is 230 pounds); however, now he is up to 245 pounds today. + DOE, PND, BLE edema. Neg for CP, n/v/d, cough/cold/URI symptoms, ha/dizziness, numbness/tingling/weakness.
ROS As per HPI
Past medical history: Diastolic CHF, hypertension, paroxysmal atrial fibrillation, pulmonary venous hypertension, coronary disease, valvular heart disease, anemia, remote lymphoma/ borderline diabetes, CKD, dyslipidemia, hypothyroid
Past surgical history: CABG, aortic and mitral valve replacement, bilateral knee surgery, coronary stents, pacemaker,
Family history: Reviewed and noncontributory to current illness
Social History: Alcohol use: Denies EtOH use; Drug use: Denies recreational drugs; Smoking status: Never Smoker
Home Medications
BUMETANIDE (BUMEX) 3 MG PO BID MEALS
LEVOTHYROXINE (LEVOXYL) 225 MCG PO DAILY@0600
METOPROLOL TARTRATE (LOPRESSOR) 12.5 MG PO BID
METOLAZONE 2.5 MG PO WK
POTASSIUM CHLORIDE ER (KLOR-CON M20) 40 MEQ PO BID
DABIGATRAN (PRADAXA) 110 MG PO BID
Sitagliptin (JANUVIA) 100 MG PO DAILY
Ferrous Sulfate (65 MG IRON)) 325 MG PO DAILY
ATORVASTATIN (LIPITOR) 10 MG PO BEDTIME
Spironolactone 25 MG PO DAY
ASPIRIN EC (ASA EC) 81 MG PO DAILY
Ezetimibe 10 MG PO DAILY
RAMIPRIL (ALTACE) 2.5 MG PO DAILY
Chemistry
Sodium (136-144MMOl/ L) 140
Potassium (3.6 - 5.1 MMOL/ L) 4.3
Chloride (98-107 MMOL/L) 102
Carbon Dioxide (22 - 32 MMOL/Ll) 31
Anion Gap (7 - 16) 7~00
BUN 7-18 mg/dl 46 H
Creatinine (0.6 - 1.3 mg/dl) 2.0 H
Estim Creat Clear calc (30 Ml/MIN) 45.498
Est GFR (African Amer)(>60 eGFR) 44 L
Est GTR(Non-Af Amer) (> 60 eGFR) 37 L
Glucose (74-106 mg/dL) 86
Calcium (8.5-10.1 mg/dL) 9.4
Magnesium (1.8-2.5 mg/dL) 2.1
Total Bilirubin (0.2-1.0 mg/dL) 0.9
AST (15-37 U/L) 29
ALT (12-78 U/L) 35
Alkaline Phosphatase (30-100 U/L) 149 H
NT-PRO-B Natriuret Pep (0-125 pg/mL) 405 H
Total Protein (6.3-8.3) 8.3
Albumin (3.6-5.0 g/dL) 4.0
General - NAD AA0x4
Eyes - Clear conjunctivae bilaterally, EOM intact
ENT - MMM
Cardiovascular - Irr Irr, 1-2+bilateral lower extremity edema
Lungs ... Clear to auscultation, no wheezing
Skin - No rashes, skin warm and dry, no erythematous areas
Abdomen - Normal bowel sounds, ntip; distended but likely fluid, firm
Extremities - No cyanosis or clubbing
Musculo Skeletal - 5/5 strength, normal range of motion, no swollen or erythematous joints
Neurological - Alert and oriented x 4, no focal deficits, normal mentation
Psychiatry - normal insight/judgement/mood
Assessment and Plan:
Acute on chronic combined diastolic and systolic heart failure exacerbation
Mitral and aortic valve disease
Acute kidney injury
AFIB/AFlutter status post ablation, currently in AFIB, on Pradaxa
CAD status post stents last in 2015
Type 2 diabetes mellitus
Hypertension/hyperlipidemia
Sleep apnea
Hx of Hodgkin's lymphoma
Hypothyroidism
VTE Prophy
IV Lasix, fluid restriction, low-sodium diet, strict 1&Os, daily weights
BNP, Serial troponin & EKG TSH echocardiogram
Monitor renal function closely -> recheck BMP @ 5pm
CHF education
Consult Cardiology
Continue home medications / Accu-Chek per insulin protocol
Follow up with a.m. labs, replace electrolytes as per sliding scale
SCDs/ on Pradaxa
Robin Sewell, CDIP, CCS, CPC, CIC, is a 25-year Healthcare Consultant and SME with a background that includes Physician, Outpatient, and Inpatient Revenue Cycle, as well as DRG and Clinical Validation audits on the Payer side of healthcare. She was previously an auditor for one of CMS RACS. Robin is the Founder and Creator of Cleopatra "Queen of Denial" Revenue Cycle Denial Management and CDI Workflow Application on behalf of providers. Her company is HIM Analytic Solutions LLC.