Q&A: PSI for hip fracture

Q: In this scenario, the patient has severe vascular necrosis and osteoarthritis/osteonecrosis of bilateral hips. She came in to have a right total hip arthroplasty (THA) and left hip core decompression. Day one after her surgery during physical therapy, she was standing and reached for a handrail in preparation to lift her left leg onto a stair and an audible pop was heard. Documentation states that she had suffered a pathologic fracture of the intertrochanteric femur on the left. Ultimately, she needed a THA on the left.

Would this be a patient safety indicator (PSI) 08, as the patient did not fall? The codes include the patient, but the PSI is “in hospital fall with hip fracture” and it doesn’t seem to fit this patient’s experience as a reportable event. 

A: The first step in dealing with PSIs is to verify the inclusion and exclusion criteria, which can be found at the Agency for Healthcare Research and Quality website here.

Once you arrive at the website, there will be an option to download the entire PSI file, which is now updated annually. Each PSI has “inclusion” and “exclusion” criteria, which CDI specialists should match against the case in question to determine if a PSI will be applied to the case.

For a case to be included in PSI 08, the following criteria must be met:

• In-hospital fall with hip fracture (secondary diagnosis) per 1,000 discharges for patients ages 18 years and older

For a case to be excluded from PSI 08, at least one of the following criteria must be met:

• Discharged cases with a principal diagnosis code (or secondary diagnosis present on admission) for hip fracture
• Any listed diagnosis code for joint prosthesis-associated fracture
• Any principal diagnosis that falls within MDC 14 (pregnancy, childbirth, and puerperium) or MDC 15 for newborns (not applicable to this case)

Because this patient did not suffer a fall, or a joint prosthesis-associated fracture, I agree with you that this case does not appear to meet the inclusion criteria for this measure. However, the ICD-10-CM code(s) will be transmitted to CMS, which will trigger the measure. Because there are always exceptions to any rule, CMS provides an opportunity for quality teams to comment on such cases. CMS provides a periodic report to qualified short-term acute care hospitals which contains cases that triggered quality measures. Quality nurses research documentation for cases included on the report and can respond with comments outlining their rationale based on documentation as to why a case should be excluded from the quality measure. CMS then has the final decision on whether or not to honor the request.

This is why we suggest including the choice on a query for a complication of “expected outcome,” when it’s applicable to do so. The fact that any complication could be an expected outcome cannot be captured by coded data, therefore a process had to be implemented as outlined above to allow for exclusions to be considered when appropriate.

Editor’s note: Dawn Valdez, RN, LNC, CCDS, CDIP, CRC, CDI education specialist at HCPro/ACDIS, which is based in Middleton, Massachusetts, answered this question. Contact her at dvaldez@hcpro.com.