Coagulopathy and Perioperative Hemorrhage and Hematoma (PSI-9)

Document coagulopathy when clinically valid and appropriate, because it reflects the seriousness of the clinical problem at hand.

“Perioperative hemorrhage and hematoma,” also known as Patient Safety Indicator (PSI) 9, is one of the PSIs developed by Agency for Healthcare Research and Quality (AHRQ). PSIs are intended to provide information on potentially avoidable safety events, representing opportunities for improvement in the delivery of care. We have long been focused on improving documentation for the purpose of maximizing the capture of complications and comorbidities (CCs) and major CCs (MCCs); however, as value-based purchasing continues to grow, the importance of improving documentation becomes more relevant and important. However, most important – and this is the theme we should always promote – is documentation for patient care. If we do that, then everything else (revenue and quality metrics) will fall into place.

For a case to be included in a PSI-9 measure, an index procedure performed in the operating room is required, a secondary ICD-10-CM diagnosis code for perioperative hemorrhage or hematoma must be present, and any listed ICD-10-PCS  procedure code for treatment of hemorrhage or hematoma (bedside or OR) must be applied.

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While the measure is titled as perioperative hemorrhage/hematoma, essentially all diagnosis codes listed in the AHRQ specification document (2020) are for postprocedural hemorrhage or hematoma. A clinically valid postprocedural hemorrhage or hematoma requires explicit documentation by the attending surgeon, establishing cause-and-effect relationship.

Unlike other PSIs, PSI-9 is not impacted by the admission type (elective, urgent, or emergent). It means that this measure is applicable to all comers into the organization. It means that in urgent/emergent admissions, wherein the attending surgeon does not have ample time to prep the patient comprehensively in terms of the coagulation system, the opportunity of documenting coagulopathy (when appropriate and clinically valid) becomes invaluable. The diagnosis of coagulopathy (D689) serves as an exclusion from the PSI-9 measure. 

In addition to coagulopathy, there are 31 additional diagnosis codes of coagulation disorders, such as pancytopenia, disseminated intravascular coagulation (DIC), Von Willebrand disease, hemophilia, and thrombocytopenia, which do serve as exclusions to PSI-9 reporting. Interestingly enough, the majority of coagulopathy codes that provide exclusion will risk-adjust the DRG as a CC or MCC.






Other constitutional aplastic anemia CC


Acquired hemophilia CC


Drug-Induced aplastic anemia MCC


Antiphospholipid antibody with hemorrhagic disorder CC


Aplastic anemia due to other external agents MCC


Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors CC


Idiopathic aplastic anemia MCC


Hemorrhagic disorder due to extrinsic circulating anticoagulants CC


Antineoplastic chemotherapy induced pancytopenia MCC


Acquired coagulation factor deficiency CC


Other drug-induced pancytopenia MCC


Other specified coagulation defects CC


Other pancytopenia CC


Coagulation defect, unspecified CC


Myelophthisis CC


Qualitative platelet defects


Other specified aplastic anemias and other bone marrow failure syndromes MCC


Immune thrombocytopenia purpura


Aplastic anemia, unspecified CC


Evans syndrome


Disseminated intravascular coagulation (defibrination syndrome) MCC


Congenital and hereditary thrombocytopenia purpura


Hereditary factor VIII deficiency MCC


Other primary thrombocytopenia


Hereditary factor IX deficiency MCC


Posttransfusion purpura


Von Willebrand disease CC


Thrombocytopenia, unspecified


Hereditary factor XI deficiency CC


Other specified hemorrhagic conditions


Hereditary deficiency of other clotting factors CC


Hemorrhagic condition, unspecified

If the patient is maintained on anti-platelets (aspirin or clopidogrel) and/or an anti-coagulant (such as Wafarin, Apixaban, Dabigatran, etc.), then the documentation of coagulopathy should be due to anti-coagulation or anti-platelets use, which if linked to the bleeding, becomes clinically valid. Specifying the underlying etiology of coagulopathy is always recommended to consolidate the clinical validity of the diagnosis.

If coagulopathy is documented on the basis of abnormal ROTEM (rotational thromboelastometry, which is a point-of-care test to assess platelet function and coagulation, primarily used in the context of trauma and liver transplantation), then additional clinical relevance, such as the need for, type, and screen in anticipation of blood products transfusion (FFP) to help achieve hemostasis, will solidify the validity of the diagnosis. Please remember that an abnormal coagulation profile (by itself) is not an exclusion from PSI-9 reporting.

When querying attending surgeons for coagulopathy, things to take into consideration include cause-effect relationship, whether the occurrence was unavoidable, and the clinical significance and resource intensity used in the management of the perioperative hemorrhage or hematoma.

Take-home message: document coagulopathy when clinically valid and appropriate, because it reflects the seriousness of the clinical problem at hand.

Programming Note: Listen to Dr. Ahmed Abuabdou report this story live during Talk Ten Tuesdays today at 10 a.m. Eastern.


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