Guest post: PSI quirks

by James S. Kennedy, MD, CCS, CDIP, CCDS

As I mentioned previously, during my review of Patient Safety Indicator (PSI) version 7.0, I came across a few quirks that I think CDI and coding professionals need to be aware of.

PSI 04, Death Rate among Surgical Inpatients with Serious Treatable Conditions: The universe for this death rate includes patients who have a surgical procedure within two days of admission or are electively admitted with any surgical procedure, and who have a deep venous thrombosis, pulmonary embolus, pneumonia, sepsis, shock, cardiac arrest, or GI hemorrhage as a secondary diagnosis, even if it is present at the time of the inpatient order (PATIO).

Critical documentation includes whether the inpatient admission was truly elective for surgeries two or more days after admission and whether the patient is transferred to another inpatient hospital.

PSI 03, Pressure Ulcer Rate: Ascertain whether any stage 3 or stage 4 pressure ulcer was PATIO, as these are excluded. Staging of pressure and non-pressure ulcers can be taken from wound care nurses; therefore, consult their expert opinions and assessments.

PSI 06, Iatrogenic Pneumothorax Rate: Any coded post-procedural pneumothorax that was PATIO is excluded. If the pneumothorax likely occurred before the inpatient order (e.g., in the emergency department), be sure to document this. Exclusions include any secondary diagnosis of a pleural effusion, chest trauma, rib fracture, and other related chest injuries. Cardiac and thoracic surgeries are excluded as well as lung or pleural biopsies or diaphragmatic repairs.

Special care must be taken in thoracic spine surgery or other procedures to document whether any resultant postoperative pneumothorax was insignificant or did not require treatment. These pneumothoraxes would not qualify as additional diagnoses and thus should not be coded, as discussed in Coding Clinic, Third Quarter, 2003, p. 19.

PSI 08, In-Hospital Fall with Hip Fracture Rate: Crucial documentation involves whether the hip fracture was PATIO or the presence of any known metastatic cancer, lymphoma, or primary bone malignancy, even if the condition is not clinically manifested but is treated with adjuvant chemotherapy (e.g., tamoxifen for breast cancer). If certain diagnoses, such as a seizure, stroke, syncope, poisoning, or other trauma, are found after study to be the condition that occasioned the inpatient admission and are sequenced as the principal diagnosis, these cases are also excluded.

PSI 09, Perioperative Hemorrhage or Hematoma Rate: These involve hemorrhages or hematomas complicating procedures that are not PATIO and requiring an operative procedure to control the bleeding or evacuate the hematoma. Differentiate between a bruise or ecchymosis; do not accidentally label these as hematomas.

A significant exclusion is any known coagulation disorder, especially those whereby the bleeding or hematoma is explicitly documented to be due to (not “with” or “while on”) aspirin or another antiplatelet agent or an anticoagulant (e.g., warfarin or Pradaxa), leading to ICD-10-CM code D68.32 (hemorrhagic disorder due to extrinsic circulating anticoagulants). Congenital or acquired coagulopathies (e.g., due to liver disease) or documented thrombocytopenia (most labs define this as a platelet count of less than 150,000; however, others use 100,000) also qualify as exclusions.

PSI 10, Postoperative Acute Kidney Injury Requiring Dialysis Rate: This involves any acute kidney injury after a surgical procedure that requires dialysis. A commonly missed exclusion is the presence of specified shock (e.g., posttraumatic, septic) that was PATIO, which may be manifested by evidence of hypoperfusion (e.g., reduced capillary refill, oliguria, mental status changes, elevated lactate levels). Patients with documented chronic kidney disease stage 5 and end-stage renal disease (ESRD) are also excluded. However, given that these are chronic conditions, they must be documented at the time of the inpatient order or stated later to have been present at that time.

PSI 11, Postoperative Respiratory Failure Rate: This involves patients documented to have acute respiratory failure after an operative procedure or those who undergo mechanical ventilation for more than 96 hours starting on the surgical date or afterwards, have mechanical ventilation for less than 96 hours that begins two or more days after surgery, or are reintubated after the surgical date. Carefully consider and explicitly document if any postoperative respiratory failure was part of the patient’s normal recovery from the procedure (e.g., less than 24 or 48 hours), in which case the post-procedural respiratory failure shouldn’t be coded at all.

Consider also, and explicitly document, whether the post-procedural acute respiratory failure is due to an underlying medical condition, such as decompensated heart failure, exacerbated COPD, or an adverse reaction to a medication and not a complication of the procedure. This allows the coder to use a code from ICD-10-CM category J96.- (respiratory failure, not elsewhere classified) that does not trigger this PSI as J95.821 (acute post-procedural respiratory failure) or J95.822 (acute and chronic post-procedural respiratory failure) does.

PSI 12, Perioperative PE or DVT Rate: Almost the only way to not trigger this PSI is for the PE or DVT to be PATIO.

PSI 13, Postoperative Sepsis Rate: Note whether an infection or sepsis was the reason for writing the inpatient order. Specify whether any of the “sepsis criteria” are in fact a systemic inflammatory response syndrome due to a non-infectious cause or whether they represent sepsis or severe sepsis. Given this is a high-weighted PSI, consider the risk-adjustment methodology cited later in this article.

PSI 14, Postoperative Wound Dehiscence Rate: Exclusions include those who are immunocompromised, evidenced by documentation of the immunocompromised state (which can be due to steroids), known specified immunodeficiencies, HIV disease (but not “+ HIV”), severe malnutrition (but not “non-severe”), pancytopenia, neutropenia, chronic kidney disease stage 5, ESRD, or transplant status.

PSI 15, Unrecognized Abdominopelvic Accidental Puncture/Laceration Rate: Coding Clinic states that any serosal tear or enterotomy that is “routinely expected” or integral to a difficult procedure should not be coded if documented as such and that any puncture or laceration should not be coded as a complication unless the physician states it is a complication. Ask your coders to reference Coding Clinic, Second Quarter 2007, pp. 11–12 for instructions.

Editor’s note: This article originally appeared in JustCoding. Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at 615-479-7021 or at jkennedy@cdimd.com. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.