ACDIS day2-12 track3-7 pres 0515 McGrady-Nagarajan f · procedures can affect criteria that ... •...

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Creating and Using an Effective Pre‐Billing Review to Identify PSIs

Mary McGrady, MSN, RN, CCDS

Director of CDI Program

Murali K. Nagarajan, CCS, MB, BS

CDI/Coding Liaison

NYU Langone Medical Center

New York, New York

Special thanks to our contributing author:

Irina Zusman, RHIA, CCS, CCDS, AHIMA‐Approved ICD‐10‐CM/PCS Trainer

Director of HIM Coding and CDI Initiatives

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• Ranked #1 in overall patient safety and quality by UHC

• #15 in the U.S. on U.S. News and World Report’s Best Hospitals Honor Roll

• Nationally ranked in 13 specialties, including top 10 rankings in orthopedics, rheumatology, rehabilitation, geriatrics, neurology, & neurosurgery

• Awarded a gold seal of approval by The Joint Commission for commitment to high‐quality care

• Magnet® Designation for Nursing Excellence


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• Consists of three hospitals on two campuses

• Total licensed beds: 1,069

• Total inpatient discharges, CY 2014:– TH: 31,581

– HJD: 5,198

• Rusk at 34th: 593

• Rusk at 17th: 1,002

• Total inpatient discharges, all facilities: 38,374

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Identify strategies for CDI to recognize potential PSIs during concurrent review

– Explain the concepts for inclusion and exclusion criteria for PSIs

– Develop tactics on how to write queries related to PSI clarification

– Discuss how as a group ACDIS members may be proactive in communication to AHRQ on concerns with AHRQ PSI technical specifications, especially in light of ICD‐10 implementation

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What Are Patient Safety Indicators (PSIs)?

• Developed at the national level by the Agency for Healthcare Research and Quality (AHRQ)

• Intended to help hospitals identify serious medical errors

• Per AHRQ, evidence shows most of the adverse events classified as PSIs are preventable

• The inclusion and exclusion criteria should account for coexisting conditions that make the adverse event less preventable

• In 2015 added to the federal Value‐Based Purchasing Program


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PSIs

• PSI 02 Death Rate in Low‐Mortality Diagnosis Related Groups (DRGs)

• PSI 03 Pressure Ulcer Rate

• PSI 04 Death Rate Among Surgical Inpatients With Serious Treatable Conditions

• PSI 05 Retained Surgical Item or Unretrieved Device Fragment Count

• PSI 06 Iatrogenic Pneumothorax Rate

• PSI 07 Central Venous Catheter–Related Blood Stream Infection Rate

• PSI 08 Postoperative Hip Fracture Rate

• PSI 09 Perioperative Hemorrhage or Hematoma Rate

• PSI 10 Postoperative Physiologic and Metabolic Derangement Rate

• PSI 11 Postoperative Respiratory Failure Rate

• PSI 12 Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate

• PSI 13 Postoperative Sepsis Rate

• PSI 14 Postoperative Wound Dehiscence Rate

• PSI 15 Accidental Puncture or Laceration

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Definitions

• PSIs measures:– By rate

– By count

• PSI measure characteristics: – Numerator cases (i.e., patient safety event)

– Denominator cases (i.e., patients at risk for having event)

• Factors that exclude a case from a denominator:– Admission type

– Diagnosis codes

– Procedure codes

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Rationale for New Process

• Number of PSIs were increasing

• Record review revealed all reported PSIs were not actual PSIs

– Documentation didn’t reflect a true picture

– The concept of PSI was new for coders, CDI, and providers

– Disconnect between different subgroups within the medical center

– PSIs were identified after billing, so if an error was found it was too late to make corrections


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The Way We Were

100107

112118

108

120121

133

0

20

40

60

80

100

120

140

2010Q1 2010Q2 2010Q3 2010Q4 2011Q1 2011Q2 2011Q3 2011Q4

AHRQ PSI Numerator Cases

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The Way We Were

0

20

40

60

80

100

120

140

160

180

Q2 2011–Q1 2012

12

Old Process

Coders review chart

Case released for billing

AHRQ PSI identified


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The New Approach –A Multidisciplinary Effort

IT/finance Coding & CDI Clinical quality department

Clinicians

Quality

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Development of New Process

IT/Finance, coding, and CQE collaborated to build electronic “flags” into Epic to identify PSI cases

CDI team reviewed all AHRQ PSI specifications to recognize potential issues on concurrent review

Coding team trained on “flags,” coding accuracy & review, and how to route the accounts

Quality department established a process for expeditious review of documentation and coding accuracy and completeness

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Resolved → Coded → Billed

CQE

•Review documentation and final coding accuracy

Coding

•Appropriate code assignment

•Appropriate POA assignment

•Completeness

CDI

•Clinical interpretation

•Diagnostic documentation clarification

•Query providers


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Coding Alerts

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Coding Alerts

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CDI Training

• Use case studies for concurrent review to demonstrate how validating certain diagnoses or procedures can affect criteria that may make a case fall into or out of the numerator

• Provide feedback from cases that are flagged once coded

• Learn from retrospective queries/review at team meetings

• Emphasize accurate documentation

• Keep up with technical spec updates and communicate to the team


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CDI Training (cont.)

• Create an environment to discuss ethical implications: – “Holistic coding” = the story coding and CDI completely ties together from an outcomes perspective

• Be cognizant of subtle pressures and stress chart integrity as goal

• 518.51, respiratory failure following trauma and surgery – Is a current MCC

– Is also PSI 11

• 999.31, other/unspecified infection central venous catheter

– Is a current CC

– Is also PSI 7 & a HAC

• Don’t let these become competing priorities

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Documentation Issue: Retrospective CDI Query (PSI 7)

Problem

• Case triggered validation check for PSI 7: Central Venous Catheter–Related Blood Stream Infection.

Review

• 84 yo female on TPN s/p diverting colostomy and colovesical fistula repair due to perforated diverticulitis admitted for TPN infusion adjustment due to labile electrolytes. Developed fever and chills and found to have positive blood cultures. Differential diagnoses included PICC line infection, PICC replaced. Coded as 999.31, infection due to central venous catheter. The reviewer noticed that the PICC tip cultures were negative.

Resolution

• The case was referred to the CDI team; physician was queried and made an addendum to the d/c summary clarifying “bacteremia of unknown source.” The code for PICC infection was removed.

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Documentation Issues: Retrospective CDI Query (PSI 3)

Problem• Case flagged for PSI 3: Pressure Ulcer.

Action

• 82 yo female with hypertension and history of CVA. Presents to ED with c/o diarrhea x 3 months. Admitted with worsening abdominal distension and leukocytosis. Developed pressure ulcer R buttock, not present on admission. Documentation included R lower extremity weakness with PT documented history of hemiparesis. CDI clarified hemiparesis residual from previous CVA.

Resolution• Code 438.21 added; this excluded this case from being reported as PSI 3.


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Documentation Issues: Concurrent CDI Query (PSI 9)

Problem

• 75 yo male transferred from outside hospital for a left carotid artery endarterectomy. Notes indicate “postop course significant for incisional hematoma.” This documentation would lead to the assignment of code 998.12, postoperative hematoma, which is PSI 9.

Action

• On concurrent review it was noted that heparin drip was initially resumed to a therapeutic level, then discontinued due to developing left neck hematoma. Heparin then resumed at a lower dose. No other procedure done to evacuate the hematoma. CDI queried for clinical significance.

Resolution

• Vascular surgeon responded and documented “the patient was on postoperative anticoagulation. Hematomas are an expected complication in the setting of anticoagulation.” This has been coded as 729.92, nontraumatic hematoma of soft tissue, and E934.2, adverse effect of anticoagulants. Coding as PSI was avoided.

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Documentation Issues: Retrospective CDI Query for POA Confirmation (PSI 12)

Problem

• The case was flagged for PSI 12. 66 yo female s/p C5 instrumentation and fusion for dens fracture in 2013, presents with hardware failure and underwent exploration of cervical fusion and C6‐7 posterior laminectomy. Neurosurgery VTE prophylaxis guidelines followed. BLE venous duplex revealed acute and subacute chronic nonocclusive deep vein thrombosis. IVC filter placed.

Action

• Noted that the patient had 2 DVTs on the same course (acute common femoral vein and chronic femoral and popliteal veins). CDI queried the neurosurgery attending asking if the acute was propagation of chronic or POA.

Resolution

• The attending replied and documented “onset of DVT unable to determine.” Assigning of POA indicator W excluded this case from the numerator.

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Documentation Issues: Concurrent CDI Query (PSI 15)

Problem

• 46 yo female with symptomatic fibroid uterus underwent supracervical hysterectomy, lysis of adhesions, repair of bowel deserosalizations. Noted in the brief op notes: COMPLICATIONS: Intraoperative consult called to general surgery to dissect bowel adhesions and repair of small bowel deserosalization.

Action

• Queried attending to clarify whether the small bowel injury was inherent to the surgical procedure or should be considered an accidental complication.

Resolution

• Attending replied to query and documented as an addendum on the operative report: “Bowel deserosalizations were encountered and repaired as an integral part of the lysis of adhesions performed by general surgery.” This prevented assigning the code 998.2 and reporting this case as a PSI.


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Intraoperative Serosal Tears Coding Clinic, Second Quarter 2007, pp. 11–12 Effective With Discharges: June 30, 2007

Question:

The patient presented with a left upper quadrant retroperitoneal cystic mass, involving intra‐abdominal organs and was brought to the operating room where she underwent radical excision of retroperitoneal cystic mass with adrenalectomy. During the procedure, the surgeon noted, "a small capsular injury of the spleen, which was hemostatic." This injury did not require repair. An esophagogastroduodenoscopy (EGD) was then performed for evaluation of the distal esophagus since the mass had adhered at the gastroesophageal junction. The EGD revealed a serosal injury to the stomach, which was repaired with interrupted Lembert sutures. The surgeon did not include the intraoperative tears in the diagnostic statement. What are the appropriate code assignments?

Answer:

Query the provider, and if the provider states the tear is not clinically significant, omit codes for both the diagnosis and procedure. When a tear is documented in the operative report, such as a small serosal tear of the stomach, the surgeon should be queried as to whether the small tear was an incidental occurrence inherent in the surgical procedure or whether the tear should be considered by the physician to be a complication of the procedure. If the provider documents that the seromuscular tear is a complication of the surgery, assign code 998.2, accidental puncture or laceration during a procedure, as an additional diagnosis. This advice is consistent with that previously published in Coding Clinic, Third Quarter 1990, p. 18.

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UHC Consensus Statement

• When punctures or lacerations are documented, it is important to differentiate between occurrences that are inherent to the procedure and those that are an accidental complication

• Query the provider for clarification:

– If the provider’s operative or postoperative procedure notes do not clearly describe the circumstances of the puncture or laceration, whether it is routinely expected or inherent to the procedure or whether it is a complication

– If the postoperative/procedure note documentation conflicts with the operative/procedure report

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Sample Query Form

Patient name:

MR#:

Date of hospital stay:

RE: Documentation Clarification

Dr. ____:

I am in the process of reviewing this chart for coding. While reviewing the record, I noted on the operative report that no complication was noted in the dictated discharge summary.

Was the __________________________

[ ] an incidental occurrence inherent to the surgical procedure or

[ ] a complication of the procedure?

Could you please respond by ___________________? Thank you so much for your assistance in getting the medical record accurately coded.

This query and your response will become part of the patient’s legal medical record and is to be considered an extension of the progress note.

Reference: AHRQ Quality Indicators Toolkit www.ahrq.gov/professionals/systems/hospital/qitoolkit


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Documentation Issues: Concurrent CDI Clarification (PSI 13)

Problem

• Clinical documentation specialist noted that general surgery consult documented postop wound infection and SIRS. There was no documentation of wound infection by the primary team. Potential to be coded as PSI 13, Postoperative Sepsis.

Action

• The attending physician was queried for clarification. Cardiothoracic surgeon documented in the next note: “Appreciate general surgery consult note, but incorrectly stated that patient had a sternal infection. She was re‐explored last week for a non‐infected mediastinal hematoma with retained clot. No signs of mediastinal or sternal infection. The patient also developed pancreatitis, which is the most probable cause of SIRS.”

Resolution

• SIRS of non‐infectious origin was coded. Reporting the case as a PSI 13 was avoided.

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Coding Issues: Basic Coding Error (PSI 9)

Problem

• 998.11, hemorrhage complicating a procedure, was initially coded, and the case was flagged for PSI 9.

Review

• 64 yo male with right renal s/p open right nephrectomy mobilization of liver and IVC thrombectomy. Noted in the op notes: “A bland thrombus in the distal cava was partially extracted and passed off as specimen. Additional vascular control was achieved. There was some back bleeding from lumbar veins. Then the remainder of the bland thrombus was evacuated from the distal vena cava.”

Resolution

• Code 998.11 removed and case no longer flagged for PSI 9.

• The case was discussed at CDI/coder meeting.

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Data Quality Issues: Admission Type Discrepancies (PSI 11)

•Problem

• Case triggered validation check for PSI 11: Postoperative Respiratory Failure.

Review

• Patient was transferred from OSH with severe aortic insufficiency. Patient developed acute respiratory failure after the valve replacement surgery. Coding was correct, but the admission type was erroneously assigned as elective.

Resolution

• Patient access contacted and admission type changed to urgent. This case no longer flagged as PSI.


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Coding Issues: Inclusions and Exclusions (PSI 10)

Problem

• Case was flagged for PSI 10: Postoperative Physiologic and Metabolic Derangement.

Review

• Patient underwent a complex revision of spinal fusion and developed postoperative urinary retention, which led to acute renal failure. The patient had to be dialyzed. Reviewer noted that the patient is on Digoxin for atrial fibrillation.

Resolution

• Code 427.31 was added to the coding summary, and this excluded the case from being reported as PSI 10.

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Coding Issues: Condition Coded Did Not Meet Clinical Criteria (PSI 11)

Problem• Case was flagged for PSI 11: Postoperative Respiratory Failure.

Action

• 68 yo male with hydronephrosis, right ureteral and pelvis mass, admitted for laparoscopic nephrectomy. In PACU noted to have stridor and bronchospasms desaturated requiring BiPAP. Respiratory failure included in two progress notes, other progress notes documented postop pulmonary insufficiency. Case did not meet NYU criteria for respiratory failure.

Resolution

• Code 518.51, postoperative respiratory failure, was changed to 518.52, postoperative pulmonary insufficiency. Case no longer flagged for PSI 11.

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It’s Time to Practice

• Case 1 – flagged for PSI 15

• Case 2 – flagged for PSI 9

• What “clues” would make you question the PSI assignment?

• Do you think a query is warranted?

• How would you word the query?

• Volunteers?


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Query Practice – Case 1Retrospective Enterotomy Documentation Clarification

Dear Dr. _____

Patient XXX

Noted in the chart: “Removed adhesions off the anterior abdominal wall. At this point, they were noted to be quite stuck and in fact some of the bowel stuck up into the incision itself. One was so tightly adherent it was required that we had to make a small enterotomy to get it off of the abdomen. We continued to lyse the adhesions under direct vision and there was a second enterotomy noted. After the second enterotomy was noted and the fact that there were still significant adhesions to be lysed, the decision was made to open the anterior abdominal incision with the hope of doing this under direct vision with the help of General Surgery.”

Could you clarify the clinical significance of enterotomy to assign code?

Example:

• Whether the enterotomy was an incidental occurrence inherent in the surgical procedure or

• Whether the enterotomy should be considered a complication of the procedure

I would appreciate if you could clarify the documentation as an addendum to your notes. This chart is on hold for billing.

Sincerely,

Your favorite CDS

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Query Practice – Case 2Retrospective Hemorrhage Documentation Clarification

Dear Dr. _____

Patient XXX

Noted in op notes: “At some point, we encountered robust venous bleeding from the right lateral recess of the canal. Using the microscope, we were able to obtain control of those large veins that were apparently related to the tumor.”

Was the bleeding

[ ] an incidental occurrence inherent to the surgical procedure or

[ ] a complication of the procedure?

Please clarify in an addendum to the medical record.

Thank you so much for your assistance in getting the medical record accurately coded.

Sincerely,

Your favorite CDS

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Then and Now – Total Number of PSIs

141139

108

99

86

48

74

59

69

74

44

84

68

60

0

20

40

60

80

100

120

140

160


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Then and Now – PSIs by Specific Indicators

Hurricane Sandy (10/29/12) caused disruption in hospital operations

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Helpful Hints

• Understand numerator and denominator.

• Know your inclusions and exclusions.

• Verify the admission type and source:

– Was it elective?

– Has the patient been transferred from SNF?

• Make sure POA status is captured correctly.

• Are you certain that a “complication” is a true complication and not inherent to the procedure?


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ICD‐10 Effect – Lost in Translation

• ICD‐10‐CM is supposed to make details/data more specific

• Many ICD‐9‐CM codes do not have direct equivalents in ICD‐10

• Boyd et al. found:

– The concepts of the ICD‐10‐CM diagnosis codes were not designed to mimic the previous PSIs

– There were only five direct comparisons from the 23 types of PSIs

– 15 additional PSIs were inaccurate to a lesser degree due to the complexity of the coding translation

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PSIs With ICD‐9‐CM Codes With No Mapping to ICD‐10‐CM

Patient Safety Indicators Explanation in PSI algorithm in ICD‐10‐CM

PSI 03, PSI 07, PSI 12, PSI 22: Pressure Ulcer, Central Venous Catheter, Postoperative Pulmonary Embolism or Deep Vein Thrombosis, Iatrogenic Pneumothorax

Four‐digit ICD‐9‐CM codes frequently used in billing practice are included in PSI calculations; however, official CMS guidelines require five‐digit ICD‐9‐CM codes. GEMs are only provided for official reimbursable codes. Concepts map forward to ICD‐10‐CM with additional detail.

EXP 1: Rate of Complications of Anesthesia EXP‐1 has become discontinued in ICD‐10‐CM.

PSI 16 and PSI 26: TransfusionPSI 16 and PSI 26 cause of no translation was due to a widespread use of parent codes.

PSI 15 and PSI 25: Accidental Puncture or Laceration Rate

10 ICD‐9‐CM codes with no official mapping to ICD‐10‐CM. In ICD‐10‐CM, 98 codes related to puncture, laceration. Complete restructure of concept focuses on injured organ first instead of procedure.

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Pathophysiology of Foreign Body and Coding in International Classification of Diseases, Ninth Edition, Clinical Modification (ICD‐9‐CM) and ICD‐10‐CM

Andrew D Boyd et al. J Am Med Inform Assoc 2015;22:19‐28

© The Author 2014. Published by Oxford University Press on behalf of the American Medical Informatics Association.http://jamia.oxfordjournals.org/content/22/1/19


A Convoluted Mapping to International Classification of Diseases, Tenth Edition, Clinical Modification (ICD‐10‐CM) for Patient Safety Indicator (PSI) 15 “Accidental Puncture”

Andrew D Boyd et al. J Am Med Inform Assoc 2015;22:19‐28

© The Author 2014. Published by Oxford University Press on behalf of the American Medical Informatics Association.http://jamia.oxfordjournals.org/content/22/1/19

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Potential Downstream Issues

• Possible over‐reporting

– If multiple ICD‐10 codes could be linked to a single event

• Possible under‐reporting

– If new coding criteria are different in ICD‐10 and the codes do not match with a PSI at all

• Changes in how injuries are reported

– Currently certain injuries are only coded in an initial encounter

– ICD‐10 has more codes to represent subsequent encounters; this could lead to incorrect reports

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Lessons Learned and Key Challenges Ahead

• Create a no blame culture – learn from failures • Use of administrative data risks capturing false events• Erroneously high number of adverse events misdirects our

quality and safety efforts, and affects our public image and VBP payment

• For the majority of real AHRQ PSI cases, quality of care was excellent

• We need to be proactive concerning any updates to the AHRQ PSI technical specifications

• Only time will tell how conversion to ICD‐10 will affect our current process

• ACDIS members should work together and use collective voice when addressing issues with documentation and coding with respect to ICD‐10


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References

• www.qualityindicators.ahrq.gov/modules/psi_overview.aspx

• AHRQ Agency for Healthcare Research and Quality PSI technical specifications. www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V45a/TechSpecs/PSI_10_Postoperative Physiologic_and_Metabolic_Derangement_Rate_V45a.pdf

• Lo, W. Document like this not that: CDI insights from the physician and CDI specialist. Journal of AHIMA, 85(7), 36‐40.

• Koop, E. (2013). Inside the documentation pressure cooker: Coders and CDI specialists feel the heat to chart in a questionable fashion. For the Record, 25(15), 10‐13.

• Farquhar, M. AHRQ quality indicators. In Patient safety and quality: An evidence‐based handbook for nurses. www.ncbi.nlm.gov.books/NBK2664

• UHC PSI Documentation Consensus Statement: Accidental Puncture or Laceration (PSI 15). www.uhc.edu/docs/49018566_PSI15ConsensusStatement.pdf

• Boyd, A. D., et al. (2015). Journal of American Informatics Association, 22, 19‐28.

• www.healthcarebusinesstech.com/icd10‐patient‐safety/

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Thank you. Questions?

[email protected]@nyumc.org

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.

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