Q&A: Missing documentation for acute kidney injury

Q: We are currently coding a chart for an acute kidney injury which has the baseline serum creatinine and urine output missing from the chart. Is there something we can do to identify additional information before we have to query the physician?

A: If you don’t have a baseline serum creatinine documented, then use the lowest level found in the medical record. If you don’t have the urine output documented, I usually go back and look at my nurses’ notes and look at the input and output documentation. That should give you the urine output.

If you still don’t have the urine output, then query the physician. You can have the physician bring those nurse notes into the chart so you can capture the levels for coding purposes. If you end up querying, have the physician explicitly explain what’s going on with the patient. Is the output down? What does the physician think could be the cause? That will ensure key words are documented in the chart, creating an accurate code.

Editor’s note: Kimberly J. Carr, RHIT, CCS, CDIP, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, director of clinical documentation at HRS in Baltimore, Maryland, answered this question in the HCPro webinar Acute Kidney Injury: Recognize Clinical Criteria for Proper Documentation, Coding.