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.
There is also no gold standard for diagnosis of AKI/ATN. Certain payers will use a specific set of criteria to support the coding of AKI and this typically differs from the criteria being used by the treating physician.
What is a clinical validity audit?
A clinical validity audit is to determine if documented diagnoses in a patient’s record are substantiated by clinical criteria. Those performing these audits will typically look for cases where the diagnosis is documented by the physician and a proper code assignment was reported, but the clinical picture of the patient does not support the diagnosis. Most often, clinical validation records that fall into audit denials are coded correctly according to coding rules and regulations. The denials are for insufficient clinical support in the record.
Is a query needed to clarify the documentation or clinical validity of the diagnosis?
We’ve all had the experience of the query that didn’t go over so well with a physician. As coders, we typically only query for clinical validity as a last resort, when the clinical indicators are lacking. When a patient is first admitted, the myriad of symptoms that the patient presents with could be for many different diagnoses that may only become evident during workup of the presenting symptoms. What is initially thought of and documented, may be ruled out during the workup and just not clearly documented as such. With that in mind, coders cannot ignore physician documentation even with the lack of clinical indicators being present. The documented diagnosis must be coded and/or clarified with a physician query if there is either conflicting or vague documentation, or if there is a lack of clinical indicators present to support that the condition exist. Coders and/or CDI should not be making the determination that a physician’s documented diagnosis does not exist based on the lack of clinical indicators. Physicians should be documenting what and why the patient has a specific diagnosis linking the clinical indicators to the condition documented and being treated.
Transparency in the physician’s documentation will help eliminate the need to query, help with errors in reporting accurate ICD-10-CM codes, as well as help with appeals for any denials that may occur.
Look for the final part of this series, Part 5, soon. In this, we will discuss common reasons given for denials and how coders can help prevent the clinical validation denials.
Authored by Kim Boy, RHIT, CDIP, CCS, CCS-P
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.