Thank you for your question about CMS832v2, Hospital Harm – Acute Kidney Injury. Per the ‘Definition’ header section, “[t]he “index” serum creatinine is defined as the lowest serum creatinine value within the first 24 hours of encounter start. If there are no serum creatinine values within the first 24 hours, then the index is the first serum creatinine value within the first 48 hours of encounter start…”. It is important to note that the index serum creatinine is only used to establish a baseline creatinine as well as identification of denominator exclusions. Further, specific to the numerator criteria for identifying and staging an AKI, the ‘Definition’ header section defines the highest normal serum creatinine values for females as 1.02 mg/dL, and for males, 1.18 mg/dL. Therefore, specific to your example, a value of 1.3 mg/dL is greater than the highest sex-specific normal serum creatinine value for males. The measure developer will evaluate whether the highest sex-specific normal serum creatinine values require updates during a future Annual Update. For purposes of identifying (1.5x increase) and staging an AKI (2x increase), as documented in the header, the logic looks for any serum creatinine obtained between 48 hours after the start of the encounter and either 30 days after the encounter or discharge and evaluates against the lowest as follows: Identifying AKI (1.5x increase): High serum creatinine value is at least 1.5 times higher than the lowest value obtained within the prior 7 days. If yes, the increase serum creatinine must be greater than the highest sex-specific normal value for serum creatinine. Staging AKI (2x increase): High serum creatinine value is at least 2 times higher than the lowest prior value (at any prior time) during the encounter. If yes, the increase serum creatinine must be greater than the highest sex-specific normal value for serum creatinine. In review of the example you provided, while your inquiry does not include dates, assuming the serum creatinine value of 0.9 mg/dL represents the index serum creatinine (if obtained within first 48 hours of encounter start), this value would not be used to evaluate for numerator compliance. For purposes of identifying an AKI (at least 1.5x increase), if the highest value during the encounter is 1.3 mg/dL and the lowest value of 0.6 mg/dL (obtained between 48 hours after encounter start) is obtained within the 7 days prior to the high value, then an AKI has been identified. Furthermore, this increase represents a 2x increase, and therefore, the numerator criteria for staging an AKI has been met. However, if the high value of 1.3 was obtained more than 7 days after the low value of 0.6, and no other values meet the criteria for a 1.5x increase, then the encounter will fail to meet the numerator criteria, because an AKI has not been identified during the encounter.

Patients admitted with initial creatinine within normal limits, received IV fluids, Creatinine decreased to 0.6mg/dl, according to CMS description lowest creatinine value in the seven-day window prior to the highest. If the highest creatinine value is 1.5 times or more, if we did not use the dilutional results is a part for the creatinine of 0.6 mg/dl and stayed with the original admission of 0.9mg/dl this case will not meet the 1.5 time the initial creatinine. AKI