Chart Check Up
Leveraging clinical perspectives for the middle revenue cycle – insights that drive impact. Offering support to keep current on clinical knowledge, coding updates, and industry trends.
Chart Check Up
Navigating Nephrology
We explore how nephrology documentation can be both clinically faithful and coder-ready, focusing on AKI vs ATN, linking diagnoses to causes, and reducing avoidable queries. We share practical tactics, from lab trend interpretation to medication reviews, and reflect on AI’s place alongside physician judgment.
• AKI and ATN terminology
• Linking diagnoses to clear etiologies
• Education tactics that make codable language second nature
• Respecting clinical judgment when criteria feel incomplete
• Lab and urine trends that signal early kidney injury
• Medication-induced nephrotoxicity as a reversible cause
• ICU triggers, systemic diseases, and combo codes
• Templates, AI assistance, and human oversight
Welcome to Chart Checkup, Clinical Perspectives for the Middle Revenue Cycle. This podcast delivers insights that drive impact in healthcare information management. Stay current on clinical knowledge, coding updates, and industry trends through expert interviews and conversations with Acuity Zone physician, CDI, and coding leaders. I'm happy to be discussing nephrology with Acuity Zone Dr. Brittany Congress. An alumnus of Mercer University School of Medicine, Dr. Congress then specialized in emergency medicine with years in emergency and urgent care settings. Following a personal passion for the kidney, she joins us to discuss a clinical perspective on neprology and documentation. Welcome to the show, Dr. Congress.
SPEAKER_01:Well, thank you so much, Bill, for having me. I'm I'm happy to be here today. And hopefully, through our conversation, we can enlighten the listeners and uh give them some good tips on how we can best code and um communicate between the doctors and the providers and the um CDI teams. So um fire away. I'm ready when you are.
SPEAKER_00:I appreciate it. Thank you. From your your perspective and your emergency medicine background, what do you feel like are some of the most common documentation challenges that are specific to nephrology?
SPEAKER_01:I would say the one that is most commonly that providers end up uh diagnosing or trying to communicate through their documentation is AKI, which stands for acute uh kidney injury. Then sometimes they'll also uh try to document the progression to something called ATN or acute tubular necrosis. The the thing that can be challenging is that when we're in medical school, we um, you know, we're taught our our biggest focus is on the patient safety, clinical decision making, and we don't get an early introduction um to coding. And so I think when doctors have their language, uh sometimes it doesn't connect with the language that the coders are looking for. And so that can be a challenge because the providers may use something like renal insufficiency. And to them, that that's synonymous with acute kidney injury, acute renal failure, but the coding specialist is unable to pick it up because um, in their language, um, it's not synonymous. So I would say there's some challenges there, um, simply that just weren't brought upon us in our in our education. And I think maybe later on, you know, we can even touch on that. What can we do to solve that dilemma so that everybody is speaking the same language?
SPEAKER_00:Do you feel like there are any sort of bumps in the road for documentation in a general sense when you're approaching nephrology?
SPEAKER_01:Well, again, I think that um comes back to what we were just talking about, um, is figuring out the language that is showing that, you know, the the clinical decision making, um, but making it as obvious to the coder as possible. So not only is it knowing just some of the words that are synonymous in the coding world, but also trying to link AKI or ATN or whatever the nephrology diagnosis is to its etiology. Um because that may that can prevent the initiation of a query, uh, which puts more work on the provider and more work on the CDI team. So if a provider can say AKI is due to hypovolemia, secondary to GI bleeding, then it that's the language that we want to talk. And if we can, as providers, learn to make it clear, it's great for the CDI teams, but also for anybody else that's reading the chart, um, any other providers, or um, you know, even if the patient were to come back and want to understand their condition uh more thoroughly, the the the language again is key. And that all comes to just educating the uh the providers.
SPEAKER_00:That's a great point. As part of the education team here at Acuity, I have uh often we we bring up the the terms for codable verbiage, but absolutely that we're looking to get that phrasing um uh uh so that it captures both an accurate picture of what has happened, but also um communicating with coders in the best way that we can.
SPEAKER_01:I was never knew so much about the how important the verbiage was, just um uh just the lack of education. And now that I know, I I feel um so empowered. And one of the things I think that would be helpful to educate is if if it can't be initiated early on in medical school and residency, I think once a patient, a person, excuse me, a provider is in a private practice or hospital setting. Having maybe, you know, monthly or quarterly group sessions where they can, you know, just make it simple and say, you know, here's what we are looking for. And that way you can have a QA session. So maybe if the provider thinks they're using the correct verbiage, maybe they've misunderstood or they had a query and they thought that you know they were all on the same page. Um, and then maybe occasional, you know, monthly email reminders and just saying, hey, everybody's doing better, or we're still seeing the same miscommunication. You know, try to remember to use acute renal failure, acute kidney injury as opposed to uh insufficiency or ATN as opposed to intrinsic. I think that would help everybody be on the same page. And and everybody, whether it's CDI or the providers, um, needs you know friendly reminders from time to time.
SPEAKER_00:Absolutely. Uh there's no question about it. And that uh in a in a past life, I I worked uh uh at a medical school. And exactly as you've said, that the the teaching components there are focused on uh so many of the important elements of a medical education, but that uh this this even idea of of needing to sort of translate or or um speak a special language almost to describe the the terminology is a a great point that is uh missing from uh the the medical uh landscape, maybe lexicon.
SPEAKER_01:Right. No, I think that's yeah, the medical landscape. I think that is that is good. And you know, the sooner it becomes it's uh we're educated, the sooner it becomes second nature. Because some people may say they have some type of administrative burden. Well, if they were to see queries as an administrative burden, they might actually be able to prevent that um and you know have more efficient workflow by using the verbiage in the first place. And if it's second nature, then you know you're not really having to um think as much about it, right? It's just it's just it's just your your language. And I think you know, education happens with the on the CDI side as well. So if let's say a provider was queried for ATN based on some of the most concrete criteria, the the creatine's elevated greater than 72 hours, greater than the patient's baseline, you know, things like that, they may think, okay, well, that's enough. But the provider may come back and say, well, there wasn't a urine analysis, or there was, but there weren't uh muddy brown casts present in the urine, or there wasn't a biopsy, so I can't make the diagnosis. And it could certainly serve as a frustration on this for the CDI team, um, because they think, well, we really do have enough criteria here to code this, or if the provider agrees to code this. But they also have to just remember it is ultimately up to the provider to decide, you know, is based on the whole clinical uh picture. It'd be nice if it was, you know, sort of cut and dry, and here's the criteria we can code. But if the provider needs a more thorough picture to make that final diagnosis as opposed to checking the box, unable to determine, CDI just has to remember, hey, they did their job, they approached it like they know, but don't let that be a source of frustration because remember, we we want that true clinical picture in the end.
SPEAKER_00:Absolutely. And I think that increasingly in this sort of new landscape of AI and everybody feeling like everything can come off of a um almost an assembly line of decision making that uh keeping the providers, uh the you know, the physician's insight and and perspective uh as a um a unique and magical thing that we definitely don't want to lose or exactly to your point, we don't want to frustrate or um degrade in any way. That I think that that's a great perspective on protecting that that valuable intellectual property that is impossible to provide other than from a physician on the ground there.
SPEAKER_01:Right, right, absolutely. Just thinking of uh, you know, going forward, artificial intelligence is certainly seems to be the wave of the future. It was actually Time magazine's person of the year, if you will, even though it's not technically a person, but it just shows you where we're going with this.
SPEAKER_00:Absolutely.
SPEAKER_01:And um I think whether providers or CDI or or anybody in the medical field wants to adjust to it, I think, I think it's just gonna come. You know, I think that's we're gonna have to figure out how to work with it. Um, but I think it's always gonna be important that it assists us in our um in the process of chart documentation and um coding accuracy. Um, I think it'll always be important, though, to have a human, you know, as a safeguard, someone to always, you know, for sort of have those checks and balances. So I think it'll be good to have the the artificial intelligence to help uh assist us and maybe with efficiency, like in a in any clinical setting, they can help take the history, ask the patient about their medications and family uh conditions and so forth, and and maybe even be able to provide a protocol that perhaps the consultant or the provider has um has initiated with the AI program, if if that allows it. Um but I think the clinical decision making will always need a uh professional um as a safeguard. And uh it'll always be important for AI, whatever their programs are, that they are in compliance with HIPAA. Um they have privacy uh protocols and um you know monitoring for any kind of data security. So it'll be interesting to see to see where we go uh moving forward.
SPEAKER_00:Uh, for sure. That uh uh we recently had an episode on denials, and that um I guess that's uh among the places where the sort of battle of AIs is laying out first uh here, and I guess that's uh makes a lot of sense, but that it is interesting to see uh AI being added as a tool, sort of on both sides of the um mid-revenue cycle there. Thinking more on AKI and ATN, when you're differentiating those two, uh what are the clinical factors that sort of carry the most weight or or impact your your thoughts the most in balancing between AKI and ATM?
SPEAKER_01:Sure. Well, we um as providers see AKI more much more frequently uh than we do ATN. And some of that is because uh with ATN, uh, as we were discussing earlier, you're gonna need that elevated creatinine above the patient's baseline for at least 72 hours uh without seeing um improvement. And so you also have to have a patient who is staying in the hospital for at least that long. Um, so you're gonna have patients that are sort of in and out that are, you know, um gonna have surgeries or you know, they had just um mild AKI. And so, you know, they're they're uh headed home uh much more quickly. But um, you know, in addition to stuff like that, you also have to um, we were mentioning earlier, sometimes you'll be looking with ATN for what are called muddy brown casts, those are found in the urine. However, there are patients that have ATN or acute tubular necrosis without the actual necrosis. And if you don't have the necrosis, then you're less likely to see the muddy brown casts. But it's still a good idea to check the urine for other things, protein, um, any presence of blood, things that might give the provider a subtle hint that something's going on. It may not be something that shows the casts, but it still may give us an idea about AKI in the early stages so that we can follow the trends in case it does progress to something like the ATN. And then, you know, if you're really not sure how to differentiate one from one kidney issue from the other, um, that's where the biopsies can come into play. Um, you know, unfortunately, the downside with that is a lot of times the pathology is not available at the time of discharge. And that does bring about the need for uh the CBI team to query the provider to make sure that they can review the pathology and agree with the diagnosis and that that diagnosis was the whether it was the primary reason for the patient's admission, or was it perhaps just a secondary uh diagnosis?
SPEAKER_00:Yeah. Oh, that's a great point uh about the the workflow, not necessarily uh um allowing the physician to capture the picture at the at the at the moment. I like that. Uh with uh considering sort of labs and pathology, uh, is there a more commonly misinterpreted renal lab, or there's um would be uh tips for a non-nephrologist, sort of well, I think I I don't know if I would necessarily say misinterpreted.
SPEAKER_01:I think there's just some subtle signs for them to be um aware of. And that would go back to what we were just talking about with the urine trends. Is there just maybe it's not a gross amount of blood or a large amount of protein, but it's just just enough to maybe say, okay, something could be going on here. And the same thing with watching the trends for the creatinine. So let's say the creatinine's not quite out of the normal range, but it's starting, there's an uptick, right? So you you really want to pay attention, all right. Something is changing. You know, let me let me look at what else might be going on, or perhaps is there some decrease in the urine output. So again, these aren't things that would maybe be misinterpreted, but things that might be overlooked. Um, the others, the other thing I would say is uh paying attention to different electrolyte abnormalities that might give, again, a subtle hint that something with the kidneys is uh is going in the wrong direction. So, for example, potassium would be something for the renal and non-renal specialists uh to follow. And also, is the patient non-compliant? Are there medicines that they should be taking uh to stay healthy, but perhaps they're not. So there's again these subtle hints that are good for the provider to watch for. So again, they don't overlook something that could be a red herring.
SPEAKER_00:That's a great perspective. That's how I should have phrased that question. I appreciate it.
SPEAKER_01:Oh, that's okay. That's great.
SPEAKER_00:Um certainly don't want to um cast dispersions in any direction that um with uh that that's a great perspective. I appreciate it. Are there some subtle signs for worsening renal injury to feel are underrecognized?
SPEAKER_01:Well, I think uh again, that probably goes back to urine output following urine analysis and uh the creatinine trends, um, along with any electrolyte uh abnormalities. And then uh also um medications. You know, sometimes we think someone's come in with uh some significant medical problem. And uh it's easy to look overlook the medications as the problem. Um, you know, when as providers, when we prescribe, we have to always weigh the benefits versus the risks. You know, we we don't prescribe unless the benefits um are certainly higher than the risk. But unfortunately, all medicines have uh potential side effects. And so you don't want to overlook the list of medicines as a possible etiology because perhaps it's going to be a somewhat straightforward, you know, fix, so to speak. Um, you know, perhaps we just need to change the medicine or withhold the medicine and and uh you know find an alternative or um you know, and and you know, provide some supportive care in the in the in-room.
SPEAKER_00:Yeah. Get them out of the danger zone there. I like it.
SPEAKER_01:That's right.
SPEAKER_00:Do you uh think of anything uh in particular relating to ICU escalation coming from kidney-related conditions?
SPEAKER_01:Yes. So if you have uh certain electrolyte abnormalities, then that can be anything from potassium, uh, magnesium, calcium, some of those can cause the um heart to go into uh an arrhythmia. And then certainly now we're, you know, we're bringing in one of the major organs in the body, and that can uh spur us on to needing that ICU admission. Um, also if the um volume status, uh, whether it's high possibly hypervolemia, then that can involve you know needing specific IV medications or drips or um possibly even some type of dialysis. So um I would say the the any kind of electrolyte abnormalities and volume status would be two things that come to mind that would might send the patient uh to the ICU faster than others.
SPEAKER_00:That's a great point. Do you see uh a relationship between systemic diseases and uh most frequently driving renal injuries?
SPEAKER_01:Yes, uh there's two that come to mind um that we see quite commonly um both in the outpatient and inpatient setting. And that would be diabetes and hypertension. And this comes back to the uh education we were talking about earlier because I certainly didn't know about combo codes, right? So you may have type 2 diabetes along with diabetic nephropathy or type 2 diabetes along with uh diabetic chronic kidney disease. And you know, that you have that code together that you could, you know, you you combine and you put that as your primary or possibly your secondary. And there's combo codes for the hypertension or hypertensive patient along with the chronic kidney disease. Uh so not only are those the systemic diseases that can lead to an acute kidney injury, but it just reminds us the more of the verbiage or the coding technique. Links that we know, again, that's going to help with our communication to the CDI team and to anyone else that's uh reading the chart.
SPEAKER_00:Absolutely. How often do you see medication induced nephrotoxicity? And what are your feelings on sort of balancing the preventability of that in an inpatient setting?
SPEAKER_01:Right. That's a good question. Um, I don't know how often I would say I see it. Um, but I again, as we were talking about earlier, um, providers always have to put patient safety first, make the uh ultimate, you know, best clinical decision that they can for the patient. And, you know, unfortunately, side effects are come with all medications. You know, we have to trust that the clinical trials and the research and the FDA that, you know, put these medications on the market, that, you know, the statistics um are accurate. Um, but we can only, you know, we have to make decisions with what we have. And that's uh going back to what we were saying earlier, too, is that we don't want to overlook the medication list because it may be a um, you know, that may be the red flag that's causing the whole issue, or may at least alleviate some of what's going on with the kidney injury by adjusting or withholding a certain medicine. So I I certainly wish we didn't have to worry about those side effects, but you know, that's just the the reality of it. And, you know, the providers make the the best clinical decision that we can with what we have. Um, and just keep in mind that, you know, if something changes to always review the uh medication list, whether it's what they were on at home or perhaps what's been started uh in the hospital setting.
SPEAKER_00:That's a great point. Are there uh certain nephrology services that you feel like uh documentation challenges uh coexist with? Like, would you say like for dialysis or procedures, there's uh some common hotspots for difficulty in documentation?
SPEAKER_01:Well, um, I certainly haven't been one that um is going to document any particular nephrology procedures. Um, but I do know that my nephrology colleagues uh have templates, just as we might have templates for our ER-specific procedures. And that allows for, you know, to be efficient and quick and make sure that you um are documenting thoroughly. Because certainly some procedures have more steps than others. And it's uh, you know, um when you're trying to move quickly and efficiently, it it's it could be easy to leave off one step, or maybe you're thinking about it, but it didn't go quite on onto the paper. Um, so having that template uh can be a great asset um for documenting uh thoroughly and preventing any kind of you know missing or uh you know missing uh verbiage or um leading to inaccurate uh charges.
SPEAKER_00:That's a great point. I really appreciate it. Do you have any uh perspective on on how documentation will be changing over the the the near future, aside from the the uh encroachment of AI? Do you see any other major trends or or changes?
SPEAKER_01:Well, hopefully, if we can get more providers educated um, you know, on the verbiage, then we might be able to get um a better documentation. And I think t whoever is creating these AI programs, making sure that they um know the proper verbiage, that it's not just um more of a standard language, you know, that's that whoever's programming it has input to say, okay, we are looking for, you know, kidney injury, kidney failure, um, as opposed to something like intrinsic or insufficiency. Because a provider may look at that and be like, oh, great, that's perfect. You know, they're talking, they're talking my language. But we've got to remember we've got the CDI that has to review afterwards. And so if AKAI can be implemented with the correct language for both the doctor and the coding um teams, then I think that will definitely be um the future that I look forward to.
SPEAKER_00:Well, that's a great perspective. Um, Dr. Crongers, I really uh appreciate your joining us here on the podcast today. Um, thank you for your time and your your perspective. We really appreciate it.
SPEAKER_01:Well, thank you so much. Uh um it's been wonderful, uh, real honor to be talking with you today. And I hope some of our listeners have taken home a few pointers that perhaps they can use for their documentation. And, you know, again, so much of it is about communication and that we, you know, we have communication is so important in everything we do in life, but especially in our um in our medical charting. So thank you again for for having me. I certainly appreciate it.
