Q&A: CKD denials

CDI Strategies - Volume 18, Issue 10

Q: Have you heard of payers requiring a creatinine change of 1.5 times the baseline when chronic kidney disease (CKD) is present? 

A: When we received your question, I did some research of my own. I’ve checked the Kidney Disease Improving Global Outcomes (KDIGO) site, Coding Clinic, and the ACDIS Pocket Guide and could not find anything like this. I also asked my colleagues and they have not heard of this. The only thing that we have heard of is not asking for a new diagnosis of CKD when acute kidney injury (AKI) is present.

Unfortunately, payers are going to try to deny almost any claim and part of our job is to make it as difficult as possible to accomplish this. I honestly don’t think a record can be made completely audit-proof, but CDI specialists can do our best to make sure the documentation is clear, concise, and appropriate for the medical record under review. 

There are a few things that may be of some help:

  • Does your organization have a particular classification/definition of AKI that they prefer the physicians use (KDIGO versus RIFLE criteria)? This may be a good educational opportunity to ensure physicians are documenting the supporting criteria for the diagnosis.
  • Are your physicians aware of not only the organization’s denial rate but also their own denial rates regarding this diagnosis? This would be another good educational opportunity.
  • Has anyone ever asked the physicians at your organization to get involved with writing appeals? Most physicians have no idea when their documentation could be related to denials. 
  • Has anyone looked at the contracts that you have with these payers to see what was agreed upon at the time the contract was signed? This may be information that could be helpful to have when appealing these denials and when it is time to renegotiate the contracts.
  • Do you have a physician advisor or champion who could do some education/re-education for you? 

When writing the appeal letters, I would also ask what criteria the payer is using. The two widely used classification systems for AKI are RIFLE criteria and KDIGO criteria. 

Finally, always remember that guidelines are there to assist physicians; they are not meant to replace the providers’ own clinical judgement. 

Editor’s note: Sharme Brodie, RN, CCDS, CCDS-O, a CDI education specialist at ACDIS/HCPro, answered this question. Contact her at sharme.brodie@hcpro.com.

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