Navigating through AHRQ PSI Inclusion and Exclusion Criteria – PSI 04

PSI 04 looks closely at the admission type of elective or any admission type where the earliest ICD-10-PCS code for an operating room is within two days of admission.

“Knowing is not understanding. There is a great difference between knowing and understanding: you can know a lot about something and not really understand it.” Charles Kettering

Knowing about the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) is not understanding them.  According to the AHRQ, “The Patient Safety Indicators (PSIs) provide information on potentially avoidable safety events that represent opportunities for improvement in the delivery of care.  More specifically, they focus on potential in-hospital complications and adverse events following surgeries, procedures, and childbirth (Agency for Healthcare Research adn Quality, n.d.).”  The AHRQ PSIs have a complex set of specifications using inclusion and exclusion criteria that is often overlooked or misunderstood.  These specifications are granular not only down to the ICD-10-CM/PCS code level but often consider admission source, admission type, and discharge disposition. 

To help facilities understand the inclusion and exclusion criteria the AHRQ has published Individual Measure Technical Specifications for each patient safety indicator.  While at baseline coding professionals understand that we not only assign ICD-10-CM/PCS codes but abstract certain data elements, we do not have a firm handle on how our downstream systems and billing systems ingest our data. There is not a strong understanding that certain data elements are properly mapped in our billing systems and are correctly reported on the claim to report the true patient story. This is where we must challenge ourselves to look beyond our coded data and step through the PSI specifications to see how our data is externally reported.

Drilling down into AHRQ PSI 04, Death Rate among Surgical  Inpatients with Serious Treatable Complications, we see that this PSI has five stratum including cardiac arrest and shock, sepsis, pneumonia, gastrointestinal bleeding, and deep vein thrombosis/pulmonary embolism.  The first thing to understand about this population is that it is the secondary diagnosis, with a present on-admission (POA) indicator of No and the discharge disposition of 20 – expired, which causes a patient to meet the criteria for PSI 04.  The PSI excludes transfers to an acute care facility and discharges admitted from a hospice facility. It is important that your admission source and discharge disposition are properly abstracted and verified in your billing systems as well as any systems used to externally report final billing and coded data.  One may pause here and question why the transfer to an acute care facility is called out.  How can a patient be transferred and expired?  This ties back to understanding your data and making sure your discharge disposition are properly captured in all downstream systems and reflected on your final claim in FL-17 of the CMS-1450 (UB04).   Chapter 25 of the Medicare Claims Processing Manual steps through each of the required billing fields for successful claims processing.   

Admission type also plays a key role in PSI 04.  PSI 04 looks closely at the admission type of elective or any admission type where the earliest ICD-10-PCS code for an operating room is within two days of admission.  If your organization’s default admission type is elective, you may be misreporting and overstating your PSI 04 if the procedure happened outside of that two-day admission window.  If you do not know how your facility’s admission type is abstracted, you need to find out and make sure it is accurate.  This is a common reporting error that is overlooked when analyzing PSI data.  Abstracting of the admission type is typically done at the point of registration and not verified at the point of coding or before final billing. 

If a discharge meets the denominator criteria for several strata, the AHRQ algorithm assigns the stratum that has the highest risk for outcome.  The stratum hierarchy is shock, sepsis, pneumonia, gi hemorrhage, and dvt/pe.  You will not be penalized for having multiple PSI 04 on a single patient.  A patient will only be counted one time regardless of the number of strata they qualify for.  However, if you have a case where you do meet an exclusion criterion for one stratum, you may still qualify for another stratum.  For example, if you have an exclusion for shock and also have a dvt/pe qualifying diagnosis and procedure, your patient will still meet for PSI 04 for the dvt/pe. 

Clinical opportunities for PSI 04 are often found to be related to present on admission indicators.  Oftentimes, due to the critical nature of a patient, the focus was getting them to the operating room for stabilization.  While there would be strong signs and symptoms present, as well as treatment for sepsis or shock, documentation may not have solidified until day 3 of the stay.  Similarly, there are times when terms such as shock and sepsis are used on admission and are not clinically supported.  Through clinical review and working with our physician advisor and clinical documentation improvement specialists, we were able to leverage our query process as well as conduct provider education to reduce those strata. 

Utilizing an appropriate present-on-admission query, we were able to have our providers exercise their clinical judgment to determine if a diagnosis was present on admission (Y), not present on admission (N), or if it was clinically unable to determine (W) due to the nature of the patient’s presentation and circumstances leading to admission.   From a PSI perspective, the POA indicator W is treated as Y for inclusion and exclusion criteria.   The POA of W means clinically undetermined.  It means that the provider is unable to clinically determine whether the condition was present at the time of inpatient admission (Novitas, n.d.).

Grow beyond “knowing” the PSIs and seek to truly understand them.  Go beyond the superficial data and dig deep into the data that is externally reported.  Understand how your electronic health record (EHR), coding system, and financial system all play a part in what is externally reported.  Look at the data elements around Admission Type, Admission Source, and Discharge Disposition to be sure that you are accurately reporting them out.  Understand how your data translates to the CMS-1450 (UB-04) fields for admission type (FL-14 priority type of admission), admission source (FL-15 point of origin), and discharge disposition (FL-17 discharge disposition).  Understand how your data maps to the required codes for these fields.  “Codes used for Medicare claims are available from Medicare contractors.  Codes are also available from the NUBC (www.nubc.org) via the NUBC’s Official UB-04 Data Specifications Manual (CMS, n.d.).” 

Leverage coding experts, CDI, and a physician champion to make sure you are truly presenting an accurate patient story.  Compare your data to the publicly available data and your cohorts.  Look for anomalies in the inclusion and exclusion data to see if you have a reporting issue.  Scrutinize your present on admission coding and make sure you put cases in question through a second level review process.  Taking your PSI review process and adding additional layers of scrutiny into your review process will turn your data around and better speak to the excellent care you are providing to patients.

References:

Agency for Healtchare Research adn Quality. (n.d.). Agency for Healtchare Research adn Quality. Retrieved October 24, 2022, from Patient Safety Indicators Overview: https://qualityindicators.ahrq.gov/measures/psi_resources

CMS. (n.d.). Medicare Claims Processing Manual. Retrieved October 24, 2022, from Chapter 25 – Completing and Processing the Form: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c25.pdf

Novitas. (n.d.). Present on admission indicators. Retrieved October 24, 2022, from https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00150103