Indiana Association of Clinical Documentation Improvement Specialists

Indiana Association of Clinical Documentation Improvement Specialists
The Impact of Clinical Documentation when assigning: Patient Safety Indicators (PSIs) and Hospital Acquired Conditions (HACs) Presented to: Indiana Association of Clinical Documentation Improvement Specialists Steven Robinson, MS-HMS, PA-O, RN, SSBB, CDIP

Value based care – a CMS promised progression
In January of 2015 CMS announced an acceleration from IPPS (fee- for-service) model to Value Based Care Congress enacts the Medicare Access and CHIP Reauthorization Act of (MACRA) Clinical care (Process application and Outcome Metrics) are to increase from 25% in 2015 to 50% by 2018. Most meaningful Penalties are also to be modified to the negative: PQRS (Physician Quality Reporting System Penalty – from 1.5% in 2015 to 2% in 2016 and beyond Meaningful Use Penalties – from 1% in 2015 to progressively 5% and higher in 2019. 2015 25% 2016 30% 2017 35% 2018 50%

Value based care – a CMS promised progression
Advanced strategies for VBC Pay for Volume (IPPS) Pay for Value (Value Based Care) Fragmented care Accountable care Treating sickness Global payment for outcomes of care Adversarial to payors Fostering preventative care Duplication and waist Potentiates Payor / Facility Partnering in care Guessing at the performance of outcomes Reliant on Meaningful Use (wired) Guessing at the cost / care ratio Support appropriateness of Venue of care

Medicare Hospital Value Payments FY 2011- 2017
Policy 2011 2012 2013 2014 2015 2016 2017 Hospital Inpatient Quality Reporting Program /a -2.0% Up to a -1.0% Meaningful Use Incentive Payments /b - .5% 1.7% 1.3% 1.4% -1.0% -3.0% Hospital Acquired Conditions (Current) /c -.02% Hospital Acquired Conditions (ACA) /d Readmissions /e Hospital Value-Based Purchasing /f 1.0% - 1.0% 1.25% - 1.25% 1.5% - 1.5% 1.75% - 1.75% 2.0% - 2.0% Percentages reflect approximate maximum potential impact to an individual hospital. Non-reporting Hospitals - Lose 2% of their annual market basket update through 2014, then lose ¼ of that update 2015 & after Incentive payments - “high adoption” scenario. Payment reductions – Non-meaningful use adopters 2015 & after. Both via market basket adjustments HACs reported through claims - loose severity adjustment Top quartile of HAC users – 1% penalty Readmissions – Lower than Benchmark face potential cut to up to a percentage ceiling Percentage of base-DRG payment - subject to meeting quality measure requirements Note: After The values in the column labeled “2017” remain constant thereafter (if all stays a planned today…)

FY 2015 Inpatient Prospective Payment System (IPPS) Final Rule:
Measures used in FY 2015 ( – ) to draft a “Measures Score” Patient Safety Indicators PSI 90 composite measure PSI 3 – Pressure Ulcer Rate PSI 6 Iatrogenic Pneumothorax Rate PSI 7 Central Venous Catheter- Related Blood Stream Infection Rate PSI 8 Postoperative Hip Fracture Rate PSI 12 Postoperative Hip Fracture Rate PSI 13 Postoperative Sepsis Rate PSI 14 Would Dehiscence Rate PSI 15 Accidental Puncture and Laceration Rate Central Line Associated Bloodstream Infections (CLABSI) measure Catheter Associated Urinary Tract Infections (CAUTI) measure FY 2016 Additions ( – – No criteria released as yet) SSI - Colon Surgeries and Abdominal Hysterectomies FY 2017 Additions ( – – No criteria released as yet) MRSA CDI

CDI to the Rescue PSI/HAC Documentation Opportunities / Impacts
The following are Patient Safety Indicators / Hospital Acquired Conditions demonstrating how clinical documentation can influence/support their use in various ways: Documentation Specifics need to support the PSI / HAC Risk averse Documentation Required Documentation Inclusions Specific PSI/HAC documentation that will exclude the PSI/HAC assignments Alternative diagnosis opportunities Most all HACs / PSIs need POA status consideration

Patient Safety Indicators (PSI)
AHRQ QI Research Version 5.0, Safety Indicators, Technical Specifications PSI-02: Death in Low Mortality DRGs PSI-03: Pressure Ulcer PSI-04: Death in surgical inpatients with Treatable complications PSI-05: Foreign Body left during Procedure PSI-06: Iatrogenic Pneumothorax PSI-07: Central Venous Catheter-related Blood Stream Infection PSI-08: Postop Hip Fracture PSI-09: Postop Hemorrhage or Hematoma PSI-10: Postop Physiologic and Metabolic Deranged PSI-11: Postop Respiratory Failure PSI-12: Postop PE or DVT PSI-13: Postop Sepsis PSI-14: Postop Wound Dehiscence PSI-15: Accidental Puncture or Laceration PSI-16: Transfusion Reaction PSI-17: Birth Trauma Injury to Neonate PSI-18: OB Trauma Vaginal Delivery with Instrument PSI-19: OB Trauma Vaginal Delivery without Instrument Orange – PSI 90 Composite Measures (CMS Adopted) Green - Reported

PSI-02: Death in Low Mortality DRGs
Coding Notes: Deaths for patients 18 or older with a low mortality Diagnosis Related Grouping – Low mortality Diagnoses list can be obtained from the CMS website. Includes: TIA, Headache, Acute Major Eye Infections, Mouth PPx, Bronchitis & Asthma, Angina Pectoris, Syncope & Collapse, Chest Pain, Knew PPx, Back & Neck PPx, Mastectomy, Major Male Pelvic PPx, C-Sections, Psychoses, Hand PPx, Rehab, etc. Excludes Trauma, Cancer w immunocompromised state, transfusion to acute care facility Documentation Specifics: Admission PDx and PPx (Sx Dx?) Reason for Admission after careful study consideration Cause of Death - End of life Diagnosis considered All secondary Diagnoses identified with associated Treatments Auto mortality Medical Record Audit Consider all Excludes notes above

PSI-03: Pressure Ulcer Coding Notes: Documentation Specifics:
Stage III or IV or unstageable pressure ulcers (SDx) for patients 18 and older Includes: Includes following Location Codes: – w Dx of Decubitus Ulcer; NOS, Elbow, Upper Back, Lower Back, Hip, Buttock, Ankle, Heel, Nec. Following Type codes: – w Dx Pressure Ulcer Stage III, IV, Unstageable Excludes: Stays less than 5 days, cases w PDx of pressure ulcer, POA and cases (examples) with hemiplegia, paraplegia, quadriplegia, spina bifida, anoxic brain damage, cases w SDx of Stage III or IV pressure ulcer or unstageable Documentation Specifics: POA, Stage, Location(s), wound description Treatment associated with Pressure Ulcer(s) Associated surgical intervention – location, description, instrumentation used Associated with systemic symptoms Consider all excludes notes above

PSI-04: Death in Surgical Inpatients with Treatable Complications
Coding Notes: In Hosp. Deaths (Disp. #20) per 100 among patients years or obstetric patients, with serious treatable complications Include: Stratum A. Respiratory Complications and Pneumonia Stratum B. Pulmonary Embolism and DVT Stratum C. Sepsis Stratum D. Shock / Cardiac Arrest Stratum E. Gastrointestinal Hemorrhage / Acute Ulcer Excludes: Transfers to other acute care facilities Exclusions specified under each complicating Dx Stratum such as: PDx w like Stratum Dx; Diagnosis with immunocompromised state or Lung CA. Documentation Specifics: If transferred to another Acute Care Facility excludes PSI Look for excludes categories for any of the Complicating Diagnoses Stratum

PSI-05: Retained Surgical Item or Un-retrieved Device Fragment Count
Coding Notes: Discharges with a retained surgical item or unretreived device fragment (as a secondary diagnosis) among surgical and medical patients 18 years or older or obstetric patients with one of the following ICD-9 codes Includes: T81.508A - T81.69XA – Adhesions, Obstructions, Perforated, Non-classified or Unspecified cases (27) with PDx or secondary Dx POA of retained Surgical item or un- retrieved devise fragment as a unspecified, secondary or PDx Diagnosis Excludes: Cases with missing Gender, Age, DQTR, Year or PDx Unspecified complication of foreign body accidentally left in body following other procedure, initial encounter Documentation Specifics: Review Excludes for associated documentation Surgical Type, Foreign Devise or Fragment Count (etc. sponge) documented

PSI-06: Iatrogenic Pneumothorax Rate
Coding Notes: Iatrogenic pneumothorax cases (secondary diagnosis) per for surgical and medical discharges for patients 18 years and older. Excludes: Chest trauma, pleural effusion PDx of Iatrogenic Pneumothorax, PDx or secondary Dx or POA Obstetric Cases Thoracic surgery, lung or pleural biopsy, diaphragmatic repair or cardiac Px Documentation Specifics: Cause of Pneumothorax if known - location Exclusions of Denominator

PSI-07: Central Venous Catheter-related Blood Stream Infection
Coding Notes: Medical and surgical patients 18 years and older or obstetric cases Includes: T80.211A – Bloodstream Infection due to central venous catheter, initial encounter T80.218A – Other infection due to central venous catheter, initial encounter T80219A – Unspecified infection due to central venous catheter, initial encounter Excludes: PDx or SDx of central venous catheter-related bloodstream infection PO Less than 2 days LOS Immunocompromised state Cases with Cancer Documentation Specifics: Location of Catheter - insertion date Type of infection and Treatment Associated Source of Infection

PSI-08: Postop Hip Fracture
Coding Notes: Surgical discharges for patients ages 18 and older with any of the following secondary diagnosis codes for hip fracture Includes: Closed and open Fractures of the femur neck, intertrochanteric or trochanteric section of the neck; femoral shaft and distal femur. Includes femoral external fixation devices Excludes: Cases susceptible to falls such as: seizure disorder, syncope, psychoses, anoxic brain injury, metastatic cancer, lymphoid malignancy, bone malignancy, disorders of the musculoskeletal system and disorders of the connective tissue. Cases with self-inflicted injury Cases with a PDx or SDx of Hip Fracture if POA Documentation Specifics: Type / Time of Fracture (POA Status) Treatment provided Fracture Exclusions present as listed above

PSI-09: Postop Hemorrhage or Hematoma
Coding Notes: Cases with control of perioperative hemorrhage, drainage of hematoma, or a miscellaneous hemorrhage – or hematoma-related procedure following surgery for surgical discharges for patients 18 and older Excludes: Diagnosis of Coagulation disorder Diagnosis of PDx or SDx of perioperative Hemorrhage or Hematoma POA ORPx is only control perioperative hemorrhage, drainage of Hematoma or misc. Hemorrhage. Documentation Specifics: Distinguish between ecchymosis (flat bruising of the skin) and hematoma (bruising with mass). Blood loss associated with Surgery Identify any exclusions listed above Treatment associated with Blood Loss

PSI-10: Postop Physiologic and Metabolic Derangement
Coding Notes: Postop Physiologic and metabolic derangement (drug or chemically induced diabetes) or acute renal failures with dialysis for surgical discharge patients 18 years or older with any of the following secondary diagnosis ICD-9 codes Excludes: Gastrointestinal Hemorrhage or Chronic Renal Failure Cases w a Diagnosis of Acute Renal Failure as a PDx or SDx POA Cases with secondary Diagnosis of Acute Renal Failure with dialysis before or on the same day as the first ORPx Cases with Acute Renal Failure with MI, Cardiac Arrhythmia, Cardiac Arrest, Shock, Hemorrhage Documentation Specifics: Type of Surgery associated with Derangement Specific type of Physiologic / Metabolic Derangement Evaluation of Excludes Options

PSI-11: Postop Respiratory Failure
Coding Notes: Postop Respiratory failure, mechanical ventilation > 96 hrs., or reintubation of surgical discharge patients 18 years and older with any of the following secondary diagnosis ICD09 codes Includes: SDx for Resp. Failure, Px w vent for > 96 hrs. that occurs 0 or more days after first major OPRx, vent for <96 hrs. that occurs 2 > days after the first major ORPx, Px for reintubation that occurs 1 > days after major OPRx Excludes: Pdx for Acute Resp. Failure, Sdx for Acute Resp Failure POA, Trach is only ORPx or occurs before the first ORPx, Neuro disorders, laryngeal/pharyngeal surg., crainiofacial disorders w Px, esophageal resection, lung CA, Resp/Circ Disorders & OB D/Cs. NOTE if intubation is for airway protection. Documentation Specifics: Respiratory Failure Acute / Chronic / Acute on Chronic – POA Status Clinical / Diagnostic Findings associated with Respiratory Failure Check for all Excludes Diagnoses – if documented as PDx or PPx no PSI

Documentation Specifics:
PSI-12: Postop PE or DVT Coding Notes: Perioperative pulmonary embolism or deep vein thrombosis (as a secondary diagnosis) for surgical discharge patients age 18 and older Excludes: Cases with PDx or SDx for Pulmonary Embolism or Deep Vein Thrombosis POA Cases in which Interruption of Vena Cava occurs before on the same day as the first operating room procedure Documentation Specifics: Surgical Procedure Review for excludes as above Treatment for PE / DVT Interventions

PSI-13: Postop Sepsis Coding Notes:
Postoperative sepsis with elective surgical discharges for patients 18 years or older Includes Examples: AO2.1 – A54.86 (Salmonella Sepsis, Sepsis due to Strep, MRSA, Gram Neg., E. coli, Pseudomonas, Candida, etc.) and R65.20/R65.21 Sever Sepsis with & w/o Shock and T81.10XA Postop Shock unspec. / T81.12XA Postop Septic Shock. Excludes: Cases with a PDx of Sepsis or pressure ulcer or cases with a SDx of sepsis POA Cases with a SDx of infection POA if w a SDx of Sepsis Cases with an Immunocompromised state Cases with Cancer Documentation Specifics: Surgical Procedure Clinical / Diagnostic Findings associated with Sepsis Treatment for Sepsis

PSI-14: Postop Wound Dehiscence
Coding Notes: Postop reclosures of the abdominal wall for surgical discharges for patients 18 years and older with the following ICD-9 secondary diagnosis code Includes: 0WQFXZZ - Reclose Postoperative disrupt Excludes: Cases in which the Abdominal Wall re-closure occurs on or before the day of the first Abdominopelvic Surgery Cases with an immunocompromised state Cases with less than two days Documentation Specifics: Surgical Procedure Description of Dehiscence - size, depth, outcomes Review all exclusions Treatment for Wound Dehiscence

PSI-15: Accidental Puncture or Laceration
Coding Notes Includes: Accidental punctures or lacerations during a ORPx patients 18 > years. Do Code or may query Provider - Accidental puncture or laceration during procedures: Infusion or transfusion, Kidney Dialysis or Perfusion, Injection or Vaccination, Endoscopy Examination, Aspiration of fluid or tissue/ cath/puncture, Special Medial Care / during enema Code Categories: E Accidental cut, puncture, perforation of hemorrhage during surgical operation, infusion/transfusion, kidney dialysis, injection, endoscopic exam, aspiration of fluid/tissue/puncture/ cath., heart cath, enema D , E , G , H – 229, H , I , J , K91.71, L , M , N Accidental puncture and laceration of systems: spleen, endocrine, nervous, ophthalmic, ear, circulatory, respiratory, digestive, dermatologic, subcutaneous, musculoskeletal, genitourinary. Excludes: Cases w Accidental Puncture or Laceration as a PDx or SDx that are POA, spinal and OB cases Do not code intentional ORPx - Terms to consider: To facilitate, Necessary, Intentional, Intended, Inherent, Integral, Routinely expected. Documentation Specifics: Location / Organ associated with Puncture / Laceration & POA status Check excludes laceration / No PSI if puncture is described with above ORPx Terms

PSI-16: Transfusion Reaction Count
Coding Notes: Medical and surgical discharges with a secondary diagnosis of transfusion reaction for patients 18 years and older or obstetric patients Includes: Code Ranges T80.30XA – T80.319A – AB Incompatibility T80.40XA – T80.49XA - Rh Incompatibility Excludes: Cases with a PDx or SDx of transfusion reaction POA Documentation Specifics: Date / Time of Infusion Treatment associated with the Transfusion Reaction Type of infusions / projected recovery Review and apply exclusions of POA

PSI-17: Birth Trauma Injury to Neonate
Coding Notes: Birth trauma rate – Injury to Neonate Excludes: Preterm infants w a BW < 2000 grams Cases w injury to brachial plexus Cases w osteogenesis imperfecta Documentation Specifics: Type of Trauma associated with Birth Distinguish between injuries post delivery Treatments associated with the Trauma See and review Exclusions above

PSI-18: OB Trauma Vaginal Delivery with Instrument
Coding Notes: Obstetric Trauma Rate – Vaginal Delivery with Instrumentation ICD-10-CM Codes Includes: O70.2 Third degree perineal laceration during delivery O70.3 Fourth degree perineal laceration during delivery Documentation Specifics: Clarify the occurrence and severity of lacerations during delivery. Type/location of Trauma associated with Vaginal Delivery Treatments associated with the Trauma No Exclusions

PSI-19: OB Trauma Vaginal Delivery without Instrument
Coding Notes: Obstetric Trauma Rate – Vaginal Delivery without Instrumentation Includes ICD-10-CM Codes: O70.2 Third degree perineal laceration during delivery O70.3 Fourth degree perineal laceration during delivery Documentation Specifics: Clarify the occurrence and severity of lacerations during delivery. Type/location of Trauma associated with Vaginal Delivery Treatments associated with the Trauma No Exclusions

PSI - 18/19 Perineal Laceration Definitions (continued)
First Degree Laceration Injury to perineal skin only Perineal laceration/rupture involving fourchette labia (posterior margin of the labia), skin, vagina, vulva or characterized as slight. Second Degree Laceration Injury to perineum involving perineal muscles but not involving anal sphincter Perineal laceration rupture or tear during delivery involving pelvic floor, perineal muscles or vaginal muscles Third Degree Injury to perineum involving anal sphincter complex 3a: Less than 50% of External Anal Sphincter thickness torn 3b: More than 50% External Anal Sphincter thickness torn 3c: Both External Anal Sphincter & Internal Anal Sphincter Torn Perineal laceration rupture or tear during delivery as in also involving anal sphincter, rectovaginal septum, or sphincter NOS Fourth Degree Injury to perineum involving anal sphincter complex (External Anal Sphincter & Internal Anal Sphincter) and anal epithelium Perineal laceration rupture or tear during delivery as in 3rd degree also involving anal mucosa or rectal mucosa Red from ACOG criteria Black from CMS ICD-10 coding description

Hospital Acquired Conditions (HAC) https://www. cms
HAC 01 - Foreign Object Retained after Surgery HAC 02 - Air Embolism HAC 03 - Blood Incompatibility HAC 04 - Pressure Ulcer Stages III & IV HAC 05 - Falls and Trauma HAC 06 - CAUTI HAC 07 - Vascular Catheter-Associated Infection HAC 08 - Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft HAC 09 - Manifestations of Poor Glycemic Control HAC 10 – Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE) with Total Knee or Hip Replacement Procedures HAC 11 - Surgical Site Infection - Bariatric Surgery HAC 12 - Surgical Site Infection Certain Orthopedic Procedures of Spine, Shoulder and Elbow HAC 13 Surgical Site Infection following Cardiac Implantable Electronic Devise (CIED) Procedures HAC 14 - Iatrogenic Pneumothorax w/ Venous Catheterization

Hospital –Acquired Conditions
Deficit Reduction Act of 2005 requires the following types of conditions be identified: High cost or high volume or both Have DRG with secondary Dx that increases the RW Cases that could reasonably have been prevented through application of evidence-based guidelines. Applicable facilities Acute Care Facilities participating in Medicare Not participating: Long-term acute care hospitals, cancer hospitals, children’s hospitals, inpatient rehab facilities, inpatient psychiatric facilities, or critical access hospitals

HAC Penalty After ; Hospitals not to receive additional payment for cases in which one of the selected conditions was not POA (case paid as though the secondary Diagnosis were not present. The “Beginning in FY 2015, the Hospital-Acquired Condition (HAC) Reduction Program, mandated by the Affordable Care Act, requires the Centers for Medicare & Medicaid (CMS) to reduce hospital payments by 1 percent for hospitals that rank among the lowest-performing 25 percent with regard to HACs”.

HAC 01 - Foreign Object Retained after Surgery
Coding Notes: Foreign object inadvertently left in patients during surgery Includes: Sponges, Instrumentation, Needles, etc. Documentation Considerations: OR Counts documented - correct/incorrect? Type of object identified, verified and documented Appropriate Timeout called and documented in the Intraoperative Record OR Count Protocol followed Perioperative or at the time of discovery Patient Intervention appropriate Readmit / POA

Documentation Considerations:
HAC 02 - Air Embolism Coding Notes: Air embolism - an air bubble that enters the blood stream and can obstruct the flow of blood to the brain and vital organs Includes: Air embolism as a complication of medical care Documentation Considerations: Assumed or verified sight of embolism entry Causation Reaction of effect of Air embolism Treatment Readmit / POA?

HAC 03 - Blood Incompatibility
Coding Notes: Transfusion with the wrong type of blood Includes: ABO incompatibility reaction, unspecified ABO incompatibility with hemolytic transfusion reaction not specified as acute or delayed ABO incompatibility with acute hemolytic transfusion reaction (CC) ABO incompatibility with delayed hemolytic transfusion reaction (CC) Documentation Considerations: Documented reaction to the blood or blood product Causation / Readmit / POA?

HAC 04 - Pressure Ulcer Stages III & IV
Coding Notes: Severe pressure ulcers Includes: Deterioration of skin, due to the patient staying in one position too long Stage III - progressed to the point that tissue under the skin is affected (MCC) Stage IV - become so deep that there is damage to the muscle and bone, and sometimes tendons and joints (MCC) Documentation Considerations: Pressure Ulcer any Stage POA? Treatment provided for Pressure Ulcer

HAC 05 - Falls and Trauma Coding Notes: Falls and Trauma Includes: Fracture, Dislocation, Intracranial Injury, Crushing Injury, Burn, Other Injuries, with any of the following secondary ICD-9 codes within these ranges Fractures of the skull and other bones Closed dislocations of joint Concussion, contusions, hemorrhage or intracranial injury Crushing Injuries Burns, epidermis and tissue loss of all degrees Conditions due to weather Documentation Considerations: Type of Trauma associated with Fall Treatment provided for Trauma POA

CAUTI: Catheter-Associated Urinary Tract Infection
HAC 06 - CAUTI Coding Notes: CAUTI: Catheter-Associated Urinary Tract Infection Includes: Infection and inflammatory reaction due to indwelling urinary catheter (CC) In and out single catheterizations with inflammation / infection (CC) Excludes the following from acting as CC/MCC: Candidiasis of other urogenital sites Conditions related to pyelonephritis Acute cystitis Urethral abscess Urinary tract infection (non-specified) Documentation Considerations: Catheter POA / UTI POA / Home self catheterizations / Systemic Symptoms? Antibiotic / Treatment prescribed?

HAC 07 - Vascular Catheter-Associated Infection
Coding Notes: Vascular Catheter-Associated Infection with on of the following secondary Diagnoses: Other and unspecified infection due to central venous catheter (CC) Bloodstream infection due to central venous catheter (CC) Local infection due to central venous catheter (CC) Documentation Considerations: Catheter POA Description of Infection / Sight / Systemic Symptoms Treatment provided for Catheter Sight / Systemic Infection

HAC 08 - Surgical Site Infection, Mediastinitis, Following CABG
Coding Notes: CABG: Coronary Artery Bypass Graft with one of the following Secondary ICD-9 codes: Includes: Mediastinitis Documentation Considerations: Describe the complexity of the Mediastinitis (depth and involvement of the infection (bone) Duration of the infection (initial or subsequent episode of care) Treatment plan POA Status

HAC 09 - Manifestations of Poor Glycemic Control
Coding Notes: Manifestations: Diabetic Ketoacidosis, Non-Ketotic Hyperosmolar coma, Secondary Diabetes with Ketoacidosis with one of the following secondary Dx: Diabetes with ketoacidosis (MCC) Diabetes with hyperosmolarity (MCC) Hypoglycemic coma (CC) Secondary diabetes mellitus with ketoacidosis (chemically/medicinally induced) Secondary diabetes mellitus with hyperosmolarity (chemically/medicinally induces) Documentation Considerations: Blood Sugars monitored - times, spikes, trends, etc. Treatment provided for Ketoacidosis Primary Diagnosis / POA Status Treatment provided for Secondary Diabetes

HAC 10 - DVT/PE Following Hip or Knee Replacement
Coding Notes: Deep Vein Thrombosis (a blood clot in a major vein) and Pulmonary Embolism (blockage in the lungs) Following certain orthopedic procedures – Total Knee Replacement & Hip Replacement with one of the following secondary Dx: Iatrogenic pulmonary embolism and infarction (MCC) Saddle embolus of pulmonary artery (MCC) Other pulmonary embolism and infarction (MCC) Acute venous embolism and thrombosis (CC) Documentation Considerations: Date of PE/DVT discovery Treatment provided for DVT/PE / Systemic Symptoms? POA status

HAC 11 - Surgical Site Infection following Bariatric Surgery Procedures Coding Notes: Bariatric Surgeries: Laparoscopic Gastric Bypass, Gastroenterostomy Laparoscopic Gastric Restrictive Surgery with one of the following secondary Dx: Morbid obesity Infection due to gastric band procedure (CC) Infection due to other bariatric procedure (CC) Other postoperative infection (CC) Documentation Considerations: Ensure BMI is in the medical record by Nursing or Nutritionist Type of infection, systemic symptoms, treatment plan POA Status

HAC 12 - Surgical Site Infection Following certain Orthopedic Procedures Coding Notes: Orthopedic Surgeries: Spine, Neck, Shoulder, Elbow with one of the following Secondary Diagnoses: Includes: Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft (CC) Documentation Considerations: Date of Surgery, Orthotic internal / external Treatment provided for / directed to Orthotic Sight Includes Orthopedic procedure and serum reaction POA Status

HAC 13 - Surgical Site Infection following CIED
Coding Notes: CIED – Cardiac Implantable Electronic Device with one of the following secondary Diagnoses Includes: Mechanical complication of other vascular device, implant, and graft (CC) Other postoperative infection (CC) Documentation Considerations: Date of Surgery, cardiac device - internal / external Treatment provided for / to cardiac device / systemic symptoms POA Status May 2, 2016

HAC 14 - Iatrogenic Pneumothorax
Coding Notes: Iatrogenic Pneumothorax (medical causation) with Venous Catheterization Includes: Iatrogenic pneumothorax with venous catheterization Documentation Considerations: Date / Time of Pneumothorax discovery Date/ Time of Venous Catheterization Treatment provided for Pneumothorax Etiology of Pneumothorax if known POA Status

PSI / HAC Match – Double Jeopardy

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