Q&A: HAC/PSI affecting quality scores

Q: If a hospital-acquired condition (HAC) or patient safety indicator (PSI) is assigned as not present on admission (POA), how does it affect our quality scores and reimbursement?

A: This is a BIG question, so I’m only skimming the surface with my answer.

Every time we have a hospital acquired condition, it counts against the facility using a scoring system for each type of injury (be it medical, surgical, or infectious). This is why POA status is extremely important for the CDI team to focus on whenever a HAC occurs.  Any condition that is present on admission does not count as a healthcare acquired condition under the HAC measures.  However, a patient can still seek care for a complication that arose from a prior healthcare episode, but because the POA status would be “no,” excludes it from the HAC measures.

PSIs were designed to indicate when a patient related injury has occurred, as well as serve as a guide for the hospitals to improve on the quality of their patient care. These carry different weights for penalties than HACs do.

PSIs are reported by the Agency for Healthcare Research and Quality (AHRQ). As of July 2019, all PSIs were updated. These are the most current definitions that will tell if a particular patient’s circumstances meet the criteria for a PSI.

For hospital value based purchasing (HVBP), there are a handful of PSIs that are grouped into a bundle known as PSI 90. They are considered to be the main focus of CMS. Currently the PSI 90 measures are suspended until 2023 for HVBP, however the “performance period” for reporting is still on-going.  More information on PSIs can be found here. 

HAC measures, however, continue to remain active and facilities do get penalized for these measures when HACs occur. Additional information can be found here. 

CDI professionals’ role is to identify when there is a possibility for a PSI or HAC and determine if a query is needed. There are a few questions that CDI specialists need to assess:

1. Is there an indication in the documentation that the condition was POA? 
2. Is there another ICD-10 code for the complication?
   
   1. For example, acute postprocedural respiratory failure is coded to J95.821 whereas acute respiratory failure codes to J96.00
   2. The coding department must have the correct code to accurately reflect if the patient’s condition as truly being a complication
3. Does the documentation show a cause-and-effect relationship between the services provided and the condition?
4. Is the condition considered “inherent” or “integral to” the procedure?  
5. Could the condition be attributed to a comorbid condition (CC) or other cause outside of the medical care?

In the example of post-operative respiratory failure, the CDI specialist would need to identify any other reason for the failure to extubate or be on oxygenation post-surgery. Here are a few questions to consider:

• Does the patient have a history of chronic obstructive pulmonary disease?
• Was the surgery involving the thoracic cavity?
• Does the patient have difficulty waking up from sedation?
• Does the patient have multiple CCs that would contribute to the patient’s condition?

If the answer to any of the above questions is yes, then gather the clinical indicators and query answer choices surrounding the circumstances and ask for clarification.

Editor’s note: The AHRQ website can be found here. Dawn Valdez, RN, LNC, CDIP, CCDS, CDI education specialist with HCPro in Middleton, Massachusetts, answered this question. For information, contact her at dvaldez@hcpro.com. For information regarding CDI Boot Camps, click here.