Acute tubular necrosis documentation

25 Oct 2020

Important clinical and coding implications

By: Dawn Gille, RN, BSN, CDS

The distinction between AKI and ATN has important clinical and coding implications, making precise documentation crucial. In order to prevent a query and/or a billing denial, the confirmed or presumed cause of AKI should be documented, concurrently and consistently, in provider progress notes as well as in the discharge summary.

The ‘gold standard’ for recognizing ATN is prolonged time to achieve creatinine response to IV fluid resuscitation. Pre-renal AKI is expected to resolve within 24 to 48 hours, whereas ATN takes at least 72 hours, but often lasts seven days or more.

Documentation of the confirmed or presumed cause of AKI has a significant impact on quality metrics and reimbursement. In coding and billing, ATN carries a higher ‘weight’ of severity of illness than does ‘simple’ AKI.

Examples of documentation related to AKI/ATN which will require a CDS to send a query:

• The diagnosis of only AKI when the patient meets clinical criteria for ATN;
• Diagnosis of AKI or ATN when there is a lack clinical indicators;
• Clinical criteria established for either AKI or ATN without Provider documentation of the condition

When AKI is due to ATN, and the clinical indicators support this diagnosis, ATN should be documented in the chart.