Q&A: PSIs and emergent procedures

Q: If a patient safety indicator (PSI) would be excluded because a procedure was emergent, do you still capture the code that would have triggered a PSI?

A: First, it’s important to remember that each PSI has a different set of criteria with very specific language as to inclusions/exclusions. 

For example, the exclusions for PSI 2 are: “Excludes trauma, cases with cancer, cases with an immunocompromised state and transfers to an acute care facility.”

In contrast, the exclusions for PSI 3 are: “Excludes stays less than three days; cases with a principal stage III or IV (or unstageable) pressure ulcer diagnosis; cases with a secondary diagnosis of stage III or IV pressure ulcer (or unstageable) that is present on admission; obstetric cases; severe burns; exfoliative skin disorders.”

Regardless of the situation or type of procedure(s), we must still capture the correct ICD-10 code is that describes the patient’s condition after applying any applicable coding guidelines just as you would with any code.

If any condition meets the criteria for a PSI, the case will be identified by the procedure code and that process is performed outside of CDI’s purview. All conditions that meet the definition of a principle and secondary diagnoses, though, should be coded as they normally would regardless of whether they’re a PSI, hospital acquired condition, or a complication. What CDI professionals need to do is ensure that the documentation for the complication shows an indication that the condition is in fact a complication and clearly details the cause and effect relationship.

Editor’s Note: Dawn Valdez, RN, LNC, CDIP, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at dvaldez@hcpro.com. For information regarding CDI Boot Camps, click here.