New Acute Kidney Injury Definition on the Horizon – And Two-Midnight Clarifications

Today I am going to start by venturing into the world of Monitor Mondays’ companion podcast: Talk Ten Tuesdays. As some know, I rarely venture into the world of clinical documentation integrity (CDI), because just thinking about whether sepsis is defined by SEPSIS-2 or SEPSIS-3 or Systemic Inflammatory Response Syndrome (SIRS) or SEP-1 gives me hives.

There are many others who are better-versed in the nuances and can better educate readers. But I will say that I always go back to what Dr. Erica Remer would say about sepsis. Her wisdom was that patients with sepsis are really sick, so if the patient in front of you is not really sick, it is unlikely they have sepsis.

That said, as many of you know, there is also controversy in what constitutes acute kidney injury (AKI). Should one use the RIFLE (Risk, Injury, Failure, Loss, End-stage) or KDIGO (Kidney Disease: Improving Global Outcomes) criteria? More significantly, how will the payer decide if the diagnosis of AKI is clinically valid?

Heck if I know. But then I saw on the Internet that the KDIGO organization had published a new draft document that would update their clinical practice guideline for AKI and acute kidney disease. Perhaps now there would be a more definitive way to diagnose AKI.

My first clue to leave this to CDI should have been that the document is 499 pages. But luckily, the section on the AKI definition was near the beginning. And the only change to the definition of AKI is that they are proposing to add the use of Cystatin-C. Is this going to help reduce the number of clinical validation denials?

Only time will tell. I hope that the Talk Ten Tuesdays CDI experts will address this once the final guidelines are released.

Next, I need to correct a few points made on Talk Ten Tuesdays last week. First, when the Two-Midnight rule came out in 2013, the Centers for Medicare & Medicaid Services (CMS) did require the admission order to be authenticated prior to discharge. But CMS removed that requirement a couple of years later. So please do not self-deny inpatient admissions when the inpatient order is not authenticated until after discharge.

Now, if your medical staff rules require authentication prior to discharge, first, get them changed, but violating those will merely get you a citation from your survey organization; you can still submit the claim and get paid for the admission.

It was also stated that for inpatient-only surgeries, the inpatient order must be placed before the surgery starts or immediately after the surgery. That is also not correct; in 2015, CMS expanded the three-day payment window to include inpatient-only surgeries.

It certainly is best to get the inpatient order preoperatively, especially if the patient will need to go to a skilled nursing facility (SNF) after hospitalization, but you do have three days to get it, as long as the patient is still hospitalized.  

Invasive mechanical ventilation was also described as “an exception” to the Two-Midnight Rule. That is partially correct but note that it does not apply to the use of mechanical ventilation for surgery. The use of general anesthesia for an elective non-inpatient-only surgery does not make it inpatient-worthy.

And finally, as many know, I am a stickler for terminology, so it is important to note that transfers and unexpected recoveries are not considered exceptions to the Two-Midnight Rule. The exceptions are for patients with a one-midnight expectation who can compliantly be admitted as inpatients.

Patients who transfer, have an unexpected recovery, or those who die or leave against medical advice, are patients who were appropriately admitted as inpatients, but an unplanned occurrence led to a shorter-than-two-midnight stay.

As the experts, it is incumbent upon us to use the right terms, even if others do not.