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By Robin Sewell, CDIP CCS CPC CIC HIM Analytic Solutions LLC |
Baseline Matters!

Coding


Baseline Matters!

Date Posted: Thursday, February 03, 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.


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Sewell, CDIP CCS CPC CIC

Robin Sewell, CDIP CCS CPC CIC

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