Why Patient Safety Indicators Matter to Medical Coders
Understand their purpose and triggers to help hospitals improve performance ratings tied to payment.
In this climate of quality care, the ability to measure and track clinical performance and outcomes within a facility is essential. The Agency for Healthcare Research and Quality (AHRQ) developed Quality Indicators for that purpose. There are four categories of AHRQ Quality Indicators: Patient Safety, Prevention Quality, Inpatient Quality, and Pediatric Quality.
We’ll focus on the Patient Safety Indicators (PSIs) and how the diagnoses and procedures you assign while coding can affect hospital safety reports.
Know Your PSIs
PSIs provide information on possible hospital complications and adverse events that may follow surgeries, procedures, and childbirth. They also help hospitals identify, assess, monitor, track, and improve the safety of inpatient care. The PSIs, as published in the AHRQ Quality Indicators™ Patient Safety Indicators brochure, are shown in Figure A.
Figure A: Patient Safety Indicators
n PSI 02 – Death rate in low-mortality diagnosis related groups (DRGs)
n PSI 03 – Pressure ulcer rate
n PSI 04 – Death rate among surgical inpatients with serious treatable conditions
n PSI 05 – Retained surgical item or unretrieved device fragment count
n PSI 06 – Iatrogenic pneumothorax rate
n PSI 07 – Central venous catheter-related blood stream infection rate
n PSI 08 – Postoperative hip fracture rate
n PSI 09 – Perioperative hemorrhage or hematoma rate
n PSI 10 – Postoperative physiologic and metabolic derangement rate
n PSI 11 – Postoperative respiratory failure rate
n PSI 12 – Perioperative pulmonary embolism or deep vein thrombosis rate
n PSI 13 – Postoperative sepsis rate
n PSI 14 – Postoperative wound dehiscence rate
n PSI 15 – Accidental puncture or laceration rate
n PSI 16 – Transfusion reaction count
n PSI 17 – Birth trauma rate – injury to neonate
n PSI 18 – Obstetric trauma rate – vaginal delivery with instrument
n PSI 19 – Obstetric trauma rate – vaginal delivery without instrument
n PSI 90 – Patient Safety for Selected Indicators
n PSI 21 – Retained surgical item or unretrieved device fragment rate
n PSI 22 – Iatrogenic pneumothorax rate
n PSI 23 – Central venous catheter-related blood stream infection rate
n PSI 24 – Postoperative wound dehiscence rate
n PSI 25 – Accidental puncture or laceration rate
n PSI 26 – Transfusion reaction rate
n PSI 27 – Postoperative hemorrhage or hematoma rate
The Role of a PSI Auditor
As the Audit and Quality Monitoring Coordinator for the Health Information Services Department at the University of Missouri Health Care, I work with PSIs daily. I review cases that have been “triggered” by our encoding system, investigate for proper coding, and work with the Office of Clinical Effectiveness in our hospital to identify possible exclusions for each case. In this process of determining if the documentation that triggered the PSI is accurate, I may need to communicate with medical coders, clinical documentation improvement specialists, nurses, skin care teams, or with the physician(s) involved in the patient’s care.
The three main PSI groups I see are pressure ulcers (PSI 03), postoperative respiratory failure (PSI 11), and perioperative pulmonary embolism or deep vein thrombosis (PSI 12).
Each PSI has an ICD-10-CM diagnosis code and/or an ICD-10-PCS procedure code that either triggers or excludes the PSI. As an example, for PSI 11: Postoperative respiratory failure rate, if a patient 18 years of age or older had an elective surgery discharge and was reintubated one or more days after the first operating room procedure, a PSI would be triggered. If the physician documented the patient as having a neuromuscular disorder (NEUROMD) or a degenerative neurological disorder (DGNEUID), however, and the diagnosis is on the denominator exclusion list (noted on the website), that case would be excluded.
Quick Tips for Coding
As a coder, it is important to understand what code assignments might trigger a PSI and to be familiar with some basics of the more common PSIs that hit your healthcare organization.
Here are some quick tips to keep in mind for three common PSI triggers:
Tip No. 1: For PSI 03, the stage of the pressure ulcer and whether it is present on admission (POA) are important components as to whether a PSI will trigger. Stage III, IV, or unstageable ulcers will create a PSI alert unless it is the principal diagnosis. Stage I, II, and ulcers that are POA Y (yes) or W (clinically undetermined) will not trigger the PSI.
Tip No. 2: For PSI 11, both J95.821 and J95.822 will trigger a PSI 11. But beware of capturing what may not be specifically noted by the physician. Unless it is documented as postprocedural respiratory failure, it is not correct to code J95.821 or J95.822 when respiratory failure simply occurs after a surgical procedure. According to ICD-10-CM Official Guidelines for Coding and Reporting FY2019, Section 1.B.16, regarding complications of care, “It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication.”
Tip No. 3: For PSI 12, establish that the DVT is proximal, as a distal DVT does not trigger the PSI. Brush up on your lower leg anatomy when dealing with a possible PSI 12 case. There are also certain acute brain and spinal injury diagnosis codes that will exclude this PSI; reading through the documentation and capturing those codes will improve hospital safety rates.
Take some time to learn about all the AHRQ QIs, and become an integral part of the quality healthcare initiative.
About the author:
Kelly Mitchell, MHA, MSHI, CPC, CPMA, CCS, started as a pro-side coder in 2011, after passing her Certified Professional Coder (CPC®) test in 2010. She became a medical coding specialist for facility-side coding in 2013 and now works in the Coding and Data Management Department at the University of Missouri Health Care. Mitchell also teaches an online course in insurance, billing, and coding for Central Methodist University. She is a member of the Silverdale Wash., local chapter.
AHRQ, Patient Safety Indicators Overview: www.qualityindicators.ahrq.gov/modules/psi_overview.aspx
AHRQ Hospital QI Toolkit: www.qualityindicators.ahrq.gov/resources/toolkits.aspx
AHRQ Patient Safety Indicator Brochure AHRQ Pub. No. 15-M053-4-EF Replaces AHRQ Pub. No. 10-M043-4, September 2015: www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V50/PSI_Brochure.pdf
Drake, Suzanne P. “Coding and Quality Measures Brief. Patient Safety Indicator 11: Postoperative Respiratory Failure Rate,” CodeWrite, January 2017.
ICD-10-CM Official Guidelines for Coding and Reporting FY 2019, Section 1.B.16: www.cms.gov/Medicare/Coding/ICD10/Downloads/2019-ICD10-Coding-Guidelines-.pdf