Query - Acute Tubular Necrosis (ATN)

Sample Query form for Acute Tubular Necrosis / Query example form for Acute Tubular Necrosis / When to query Acute Tubular Necrosis / Query format for Acute Tubular Necrosis.

Acute Tubular Necrosis (ATN) Query form

Documentation in the medical record indicates that this patient has been admitted with or diagnosed as having ACUTE KIDNEY INJURY. The following is also documented in the medical record:

• ·       Creatinine levels [list all and dates]
• ·       FENa =
• ·       Urine sodium concentration =
• ·       Urine output of _________ over ___ hours
• ·       IV contrast
• ·       Medication [if potentially neurotoxic]:
• ·       Other:

Based on your medical judgment, can you further clarify in the progress notes confirmed or suspected underlying cause for this patient’s condition such as:

• ·       Acute Tubular Necrosis
• ·       Acute Cortical Necrosis
• ·       Acute Glomerulonephritis
• ·       Pre-Renal Acute Kidney Injury
• ·       Other condition: (please specify)
• ·       None of the above /Not applicable

In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular diagnosis is desired or expected.

Thank you!

Forceps Transbronchial Biopsy

 

This is to inform everyone that there has been a change of advice from AHA Coding Clinic on the correct coding of transbronchial biopsies performed with the use of forceps.

 

The original response from AHA Coding Clinic stated that documentation of the use of forceps to perform transbronchial biopsies was not sufficient to determine the root operation performed (Excision or Extraction). A provider query should be submitted to determine the correct root operation for ICD-10-PCS code assignment.

 

AHA Coding Clinic recently submitted the question to the Editorial Advisory Board (EAB) and has now updated their response. EAB has reviewed and stated “Forceps are a type of cutting tool. Typically, forceps are used to remove an intact piece of tissue and the use of forceps is coded to the root operation Excision, whereas a needle aspiration is a collection of individual cells and is coded to the root operation Extraction.”

 

When transbronchial biopsies are performed with the use of forceps should be coded to the root operation Excision per EAB advice. Please note, this applies to forceps transbronchial biopsies only. Transbronchial needle aspiration biopsies and transbronchial Cryobiopsies should still be coded to the root operation Extraction.

QUERY - Acute Kidney Injury

Sample Query form for Acute kidney injury / Query example form for Acute kidney injury / When to query Acute Kidney Injury / Query format for Acute kidney injury

 

Acute Kidney Injury Query Form

Documentation in the medical record indicates that this patient has been admitted with or diagnosed as having .

 

The following lab is also documented in the medical record: [include criteria that apply]

· Creatinine on admission =

· Baseline Creatinine (if known):

· Correction of serum creatinine from ____ to _____ following rehydration

· Urine output :

 

Based on your medical judgment, can you please clarify in the progress notes the diagnosis associated with these findings such as:

· Acute Kidney Injury

· Acute on Chronic Renal Failure

· Chronic Kidney Disease (Stage, if known)

· Other (please specify)

· None of the above / Not applicable

 

In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular diagnosis is desired or expected.

 

Thank you!

CMS POA Indicators

 CMS POA Indicator Options and Definitions

Code	Reason for Code
Y	Diagnosis was present at time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as "Y" for the POA Indicator.
N	Diagnosis was not present at time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as "N" for the POA Indicator.
U	Documentation insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as "U" for the POA Indicator.
W	Clinically undetermined.  Provider unable to clinically determine whether the condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as "W" for the POA Indicator.
1	Unreported/Not used.  Exempt from POA reporting.  This code is equivalent to a blank on the UB-04, however; it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as "1" for the POA Indicator. The “1” POA Indicator should not be applied to any codes on the HAC list.  For a complete list of codes on the POA exempt list, see  the Official Coding Guidelines for ICD-10-CM.