Is Documentation Present to Report Acute Kidney Injury?

Is the diagnosis clearly documented without conflict?

As coders, we know the importance of having complete and accurate documentation in a patient’s health record. Without having this, there’s no way that accurate coding can take place. If there is question of a diagnosis being present in the record or even conflicted by another physician, a query is needed to clarify. While reviewing the health record, coders should look for the following (non all inclusive):

• Clear documentation of the diagnosis of AKI
• Conflicting documentation such as acute kidney/renal insufficiency
• Lack of improvement in labs
• Labs that don’t show any evidence of AKI such as within normal limits of BUN and creatinine
• Documentation of chronic kidney disease (CKD) along with a diagnosis of AKI without improvement to baseline (could be natural progression of CKD)
• Treatment directed toward the diagnosis of AKI, monitoring, therapeutic treatment, diagnostic procedures or extended length of stay
• Is urine output being monitored?
• Did the lab values improve to normal or baseline within just a few hours?

Are there clinical indicators to support the diagnosis?

It is very tough for coders to determine how to report a diagnosis documented by a physician when there is little to no clinical indicators for the condition present. Clinical documentation improvement (CDI) specialist can help reduce the amount of question on a diagnosis, by helping the physician bring forward the criteria that is being used to make the stated diagnosis.

Coders wear many different hats these days. In the past, the coders role was to report a proper code for documented diagnoses by the physician. It’s a balancing act that coders go through with every record they code. Coders are oftentimes responsible to evaluate the clinical indicators that are present for a documented diagnosis, and if there aren’t sufficient indicators, query the physician. This is on top of determining if each diagnosis meets the reporting requirements such as monitoring, evaluation, treatment, or extended length of stay. CDI specialists, facilities, and coders need to help physician’s understand the need to link the clinical indicators in the record (such as laboratory findings), to the specific diagnosis being made when this specific clinical finding is evaluated. There should be transparency in the physician’s diagnosis and the link of clinical support for the same.

To learn more and see examples, purchase our Acute Kidney Injury eBook.