Drive Positive Impacts on PSI, HAC, and Other Value-Based Models

Drive Positive Impacts on PSI, HAC, and Other Value-Based Models
Amy Czahor, RHIT, CDIP, CCS VP, Optimization and Analytics Services RecordsOne Tom Scholomiti, RHIT Senior Director, nSight Strategy & Implementation

Learning Objectives At the completion of this educational activity, the learner will be able to: Identify HAC and PSI impacts to publicly reported data and reimbursement models Identify inclusion and exclusion criteria for each measure as well as potential coding and provider query opportunities to improve measure performance Discuss initiatives at a large healthcare system to bring together an interdisciplinary team and build processes for best practice of HAC and PSI review Leverage technology to identify and prioritize case review

Hospital-Acquired Conditions (HACs)
A hospital-acquired condition (HAC) is one of several specific medical conditions a patient can acquire during a hospital stay that was not present on admission (POA). It is a designation used by the Centers for Medicare & Medicaid Services (CMS) since October 1, 2008 that may result in adjusting Medicare Severity Diagnosis-Related Group (MS-DRG) payments.

CMS HAC Provisions DRA HAC payment provision DRA HAC reporting
HAC Reduction Program Under the DRA HAC payment provision hospitals no longer receive additional payment for cases in which one of the selected conditions occurred but was not present on admission (POA). That is, the case is paid as though the condition were not present. The DRA HAC-POA payment provision is applicable for secondary diagnosis code reporting only - as the selected conditions are designated as a complication or comorbidity (CC) or a major complication or comorbidity (MCC) when reported as a secondary diagnosis. For the DRA HAC-POA payment provision, a payment adjustment is only applicable if there are no other CC/MCC conditions reported on the claim. CMS calculates and reports rates for four of the conditions included in the DRA HAC payment provision, this is what is referred to as DRA HAC Reporting. The DRA HAC measures are only reported for information and quality improvement purposes, and are not a part of the HAC Reduction Program. The HAC Reduction Program is a separate Medicare hospital payment program that supports CMS’s long-standing efforts to improve patient safety and link Medicare’s payment system to healthcare quality provided in the inpatient hospital setting. Section 3008 of the Affordable Care Act established the HAC Reduction Program to provide an incentive for hospitals to reduce HACs.

DRA HAC Payment Provision
HAC 01 – Foreign Object Retained After Surgery HAC 02 – Air Embolism HAC 03 – Blood Incompatibility HAC 04 – Stage III and IV Pressure Ulcers HAC 05 – Falls and Trauma HAC 06 – Catheter-Associated UTI (CAUTI) HAC 07 – Vascular Catheter–Associated Infection (CLABSI) HAC 08 – SSI – Mediastinitis After CABG HAC 09 – Manifestations of Poor Glycemic Control HAC 10 – DVT/PE With Total Knee or Hip Replacement HAC 11 – SSI – Bariatric Surgery HAC 12 – SSI – Orthopedic Procedures of Spine, Shoulder, and Elbow HAC 13 – SSI Following CIED Procedures HAC 14 – Iatrogenic Pneumothorax w/ Venous Catheterization

DRA HAC Reporting For 2017, CMS will publicly report the following measures: Foreign Object Retained After Surgery Blood Incompatibility Air Embolism Falls and Trauma Used shortened 15-month performance period (7/14–9/15) Results posted August 2017 CMS selected the four DRA HAC because no measures in other CMS quality programs cover these topics. Performance period July 2014-September 2015

Strategies Identify concurrently, NOT retrospectively
Leverage your clinical documentation programs Based on codes Leverage technology Based on words Comprehensive education of all stakeholders Establish a HAC reconciliation and escalation process

Hospital-Acquired Condition (HAC) Reduction Program
Patient Protection and Affordable Care Act (ACA) established the Hospital Acquired Condition (HAC) Reduction Program to encourage eligible hospitals to reduce HACs. Worst performing quartile subject to 1 percent payment reduction.

FY18 Changes Replace the decile-based scoring method with the Winsorized z-score methodology Use a shortened 15-month data period for the Patient Safety Indicator (PSI) 90 Composite in Domain 1 Use an updated version of the PSI 90 Composite Use the re-baselined CLABSI, CAUTI, SSI, MRSA, and CDI measures Use CLABSI and CAUTI measures expanded beyond ICUs to include data from medical, surgical, and medical-surgical wards Remove the No Facilities waiver for the CLABSI and CAUTI measures

Public Reporting Recalibrated PSI 90 Composite measure score
Central Line–Associated Bloodstream Infection (CLABSI), Catheter-Associated Urinary Tract Infection (CAUTI), Surgical Site infection (SSI), Methicillin- Resistant Staphylococcus Aureus (MRSA) Bacteremia, and Clostridium Difficile Infection (CDI) measure scores Domain 1 and Domain 2 scores Total HAC score Payment Reduction Indicator CMS will report the following FY 2018 HAC Reduction Program information for each hospital on Hospital Compare in December 2017:

Recalibrated PSI 90 PSI 03 – Pressure Ulcer Rate
PSI 06 – Iatrogenic Pneumothorax Rate PSI 08 – In-Hospital Fall With Hip Fracture Rate PSI 09 – Perioperative Hemorrhage or Hematoma Rate PSI 10 – Postoperative Acute Kidney Injury Requiring Dialysis 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 – Unrecognized Abdominopelvic Accidental Puncture/Laceration Rate The recalibrated PSIs used in CMS hospital quality reporting programs focus on the Medicare Fee-for-Service (FFS) population. CMS refers to PSIs as “recalibrated” to differentiate from the all-payer population for AHRQ. Derived from data from July 2013 through June 2015 Medicare Fee-for-Service (FFS) claims. In FY 2018, CMS bases hospitals’ Recalibrated PSI 90 Composite performance on 15 months of data rather than 24 months. More hospitals’ will have PSI 90 Composite results close to the mean.

CDC NHSN Healthcare-Associated Infection Measures
Central Line–Associated Bloodstream Infection (CLABSI) Catheter-Associated Urinary Tract Infection (CAUTI) Surgical Site Infection (SSI) Colon Abdominal hysterectomy Methicillin-Resistant Staphylococcus Aureus (MRSA) bacteremia Clostridium Difficile Infection (CDI) The CDC calculates standardized infection ratios (SIRs) for the CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI measures. SIRs compare observed-to-predicted numbers of healthcare associated infections (HAIs). The CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI measures are risk-adjusted at the hospital level and patient care unit level. CDC used chart-abstracted and laboratory surveillance data from NHSN for infections occurring from January 1, 2015 through December 31, Hospitals’ Domain 2 measure results will differ between FY 2018 and previous program years due to rebaselining and the expansion of the CLABSI and CAUTI measures to include ward data.

Hospitals cannot directly compare measure scores, domain scores, and Total HAC Scores between FY 2018 and previous program years. These results are on different scales. The domain weights for FY 2018 are the same as FY CMS applies a weight of 15 percent for Domain 1 and 85 percent for Domain 2 to determine the Total HAC Score for hospitals that receive a Domain 1 score and a Domain 2 score. If a hospital has only one domain score, then CMS applies a weight of 100 percent to the domain for which the hospital has a score. Hospitals with a Total HAC Score above the 75th percentile of the Total HAC Score distribution will receive a payment reduction.

Domain 2: CDC NHSN Healthcare-Associated Infection Measures
CLABSI, CAUTI, SSI, MRSA, and CDI

FY18 Final Rule “In addition, CMS is also responding to comments received on adoption of additional measures, accounting for social risk factors, and inclusion of disability and medical complexity in the CDC NHSN measures.” This is a bit controversial. Leapfrog group has spoken out directly stating they “Don’t support any adjustment for social factors to patient safety measures or payment programs focused on reducing patient harm, such as the HAC Reduction Program”

Best Practices Attack on all fronts with interdisciplinary approach
Perform retrospective root cause analysis and categorize: Clinical issue? Ambiguous documentation? Overzealous querying? Coding error? Work with data analysts or application analysts to identify risk criteria for your patient population So what can we do? We spoke earlier about the importance of educating quality staff, physicians, coders, and clinical documentation specialists. Involve your infection control/prevention department. Involve your infectious disease medical directors. Involve your chiefs of surgery. Many of the organizations I’ve been involved in have interdisciplinary mortality meetings where each chart is reviewed in detail but often HACs and PSIs are not afforded the same resources. Take best practices from your mortality review process and expand it. Take advantage of LEAN resources within your organization. One of the organizations I’ve worked with identified that as many as 40% of reported HAIs were do to questionable queries or coding errors. We spoke previously about the importance of concurrent identification, you also need to be looking for patients at risk for being coded.

Domain 1 Recalibrated PSI 90

AHRQ FAQs on V7.0 ICD-10-CM/PCS Beta Software
“At least one full year of data coded in ICD-10-CM/PCS is needed to develop robust risk adjustment models for the ICD-10-CM/PCS compatible software. A full year of ICD-10-CM/PCS coded all-payer data will not be available until summer of 2018; therefore, risk- adjustment capabilities for ICD-10 software are anticipated at the end of 2018.”

PSI 03 – Pressure Ulcer Rate
Stage 3 or 4 pressure ulcers or unstageable pressure ulcers (secondary diagnosis) per 1,000 discharges among surgical or medical patients ages 18 years and older Excludes: Stays less than 3 days Cases with a principal diagnosis of pressure ulcer Cases with a secondary diagnosis of Stage 3 or 4 pressure ulcer or unstageable pressure ulcer that is present on admission Cases with major skin disorders Obstetric cases Cases with hemiplegia, paraplegia, quadriplegia, spina bifida, or anoxic brain damage Cases in which debridement or pedicle graft is the only operating room procedure Discharges with debridement or pedicle graft before or on the same day as the major operating room procedure Transfers from another facility Make sure all integumentary assessments upon admission in both nursing and provider documentation are reviewed thoroughly Involve wound care or PUP team as necessary Look for query opportunity for unilateral weakness

PSI 06 – Iatrogenic Pneumothorax Rate
Iatrogenic pneumothorax cases (secondary diagnosis) per 1,000 surgical and medical discharges for patients ages 18 years and older Excludes: Cases with chest trauma, pleural effusion, thoracic surgery, lung or pleural biopsy, diaphragmatic repair, or cardiac procedures Cases with a principal diagnosis of iatrogenic pneumothorax Cases with a secondary diagnosis of iatrogenic pneumothorax present on admission Obstetrics cases

Coding Clinic, First Quarter 2011, p. 14
Question: Please provide clarification on the reporting of code 512.1, Iatrogenic pneumothorax. I understand the guideline for chapter 17, Injury and poisoning ( ) regarding complications of care that states that "code assignment is based on the provider's documentation of the relationship between the condition and the procedure" (Section I.C.17.f.1.a). Does this guideline extend also to code 512.1, which is in the Respiratory System chapter? Does the provider need to document that the pneumothorax is a complication before assigning code 512.1? Answer: If the provider documents iatrogenic pneumothorax or documents that the pneumothorax is due to a procedure, code 512.1, Iatrogenic pneumothorax, should be assigned. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following surgery are classified as complications. First, there must be more than a routinely expected condition or occurrence. In addition, there must be a cause-and- effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication.

PSI 08 – In-Hospital Fall With Hip Fracture Rate
In-hospital fall with hip fracture (secondary diagnosis) per 1,000 discharges for patients ages 18 years and older Excludes: Cases that are susceptible to falling (seizure disorder, syncope, stroke, occlusion of arteries, coma, cardiac arrest, poisoning, trauma, delirium or other psychoses, anoxic brain injury, metastatic cancer, lymphoid malignancy, bone malignancy, disorders of the musculoskeletal system, and disorders of connective tissue) Cases with self-inflicted injury Cases with a principal diagnosis of hip fracture Cases with a secondary diagnosis of hip fracture present on admission Obstetrics cases Dementia Substance Abuse/Dependence Metastatic Malignancy – Avoid “Stage IV Cancer” Symptom Coding

ICD-10-CM General Coding Guidelines
Signs and symptoms Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Conditions that are an integral part of a disease process Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. Conditions that are not an integral part of a disease process Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.

PSI 09 – Perioperative Hemorrhage or Hematoma Rate
Perioperative hemorrhage or hematoma cases involving a procedure to treat the hemorrhage or hematoma, following surgery per 1,000 surgical discharges for patients ages 18 years and older. Excludes: Cases with a diagnosis of coagulation disorder Cases with a principal diagnosis of perioperative hemorrhage or hematoma Cases with a secondary diagnosis of perioperative hemorrhage or hematoma present on admission Cases where the only operating room procedure is for treatment of perioperative hemorrhage or hematoma Obstetrics cases Check labs for thrombocytopenia or any type of coagulopathy, especially if patient is on anticoagulants

Postoperative Coagulopathy Secondary to Medication Question: This patient underwent an emergency ileocecectomy. The patient's stay was complicated by postoperative coagulopathy and intra-abdominal hemorrhage due to prasugrel and aspirin taken as prescribed prior to admission. What is the appropriate code for the acquired coagulopathy secondary to prasugrel and aspirin? Answer: Assign code D68.32, Hemorrhagic disorder due to extrinsic circulating anticoagulants, along with codes T45.525A, Adverse effect of antithrombotic, Initial encounter, T39.015A, Adverse effect of aspirin, Initial encounter, and K91.840, Postprocedural hemorrhage and hematoma of a digestive system organ or structure following a digestive system procedure. Prasugrel (Effient®) is a platelet inhibitor and works by keeping the platelets in the blood from coagulating to prevent unwanted blood clots that can occur with certain heart or blood vessel conditions. It is used to prevent blood clots in people with acute coronary syndrome who are undergoing a procedure after a recent heart attack.

I, Fourth Quarter 2016, p. 99 ICD-10-PCS New/Revised Procedure Codes: Section 0- Medical and Surgical: Root Operation Control The definition of the root operation "Control" was revised. From To Root Operation Control: Stopping, or attempting to stop, postprocedural bleeding Control: Stopping, or attempting to stop, postprocedural or other acute bleeding The change in the root operation definition was to address situations when no other root operation applied, but the bleeding that was being controlled was not postprocedural. The root operation "Control" can now be used for controlling/stopping other types of acute bleeding, in addition to postprocedural bleeding.

PSI 10 – Postoperative Acute Kidney Injury Requiring Dialysis Rate
Postoperative acute kidney failure requiring dialysis per 1,000 elective surgical discharges for patients ages 18 years and older Excludes: Cases with principal diagnosis of acute kidney failure Cases with secondary diagnosis of acute kidney failure present on admission Cases with secondary diagnosis of acute kidney failure and dialysis procedure before or on the same day as the first operating room procedure Cases with acute kidney failure, cardiac arrest, shock, urinary tract obstruction, or chronic kidney failure Obstetrics cases

PSI 11 – Postoperative Respiratory Failure Rate
Postoperative respiratory failure (secondary diagnosis), prolonged mechanical ventilation, or reintubation cases per 1,000 elective surgical discharges for patients ages 18 years and older Excludes: Cases with principal diagnosis for acute respiratory failure Cases with secondary diagnosis for acute respiratory failure present on admission Cases in which tracheostomy is the only operating room procedure or in which tracheostomy occurs before the first operating room procedure Cases with neuromuscular disorders; laryngeal, pharyngeal, or craniofacial surgery; esophageal resection; lung cancer; lung transplant; or degenerative neurological disorders Cases with a procedure on the nose, mouth, or pharynx Cases with respiratory or circulatory diseases Obstetrics discharges

Discuss - Sutter Anesthesia Pilot

Coding Clinic, Fourth Quarter 2014, p. 3
Under normal circumstances, mechanical ventilation that is being used during a surgical procedure is not coded separately, and neither is the endotracheal intubation. If, however, the patient remains on mechanical ventilation for an extended period (several days) post surgery, the mechanical ventilation should be reported. Even if the postsurgical patient is not extubated within the expected postoperative time frame, and requires extended mechanical ventilatory support, the ET intubation would not be "retroactively" coded.

PSI 12 – Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate
Perioperative pulmonary embolism or proximal deep vein thrombosis (secondary diagnosis) per 1,000 surgical discharges for patients ages 18 years and older. Excludes: Cases with principal diagnosis for pulmonary embolism or proximal deep vein thrombosis Cases with secondary diagnosis for pulmonary embolism or proximal deep vein thrombosis present on admission Cases in which interruption of vena cava occurs before or on the same day as the first operating room procedure Any-listed ICD-10-PCS procedure code for extracorporeal membrane oxygenation (ECMO) Any-listed ICD-10-CM diagnosis code for acute brain or spinal injury present on admission Obstetrics discharges Discuss Sutter case. Importance of verifying in previous records that patient doesn’t have a history of previous DVT in same location and that it may be chronic.

Chronic Venous Embolism and Thrombosis Question: Given the codes for chronic venous embolism and thrombosis, when does DVT become chronic? Answer: There are no specific timelines for when DVT or any other condition becomes chronic. The assignment of chronic DVT should be based on provider documentation.

History of Deep Vein Thrombosis on Coumadin Therapy Question: A patient with a documented "history of deep vein thrombosis" is receiving Coumadin. Should this be coded as V12.51, Personal history of venous thrombosis and embolism, or a code from category 453 for chronic deep vein thrombosis (DVT)? Answer: Either code may be appropriate depending on the circumstances. Query the physician for clarification whether the Coumadin is being given prophylactically to prevent recurrence of DVT or as treatment for chronic DVT. The patient may not have active disease but is being managed because of susceptibility for recurrence. Unfortunately, "history" as used in physician documentation can be a vague term that can have different meanings. According to the Official Guidelines for Coding and Reporting, "personal history codes explain a patient's past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require monitoring." Coders are assigning a code for history of deep vein thrombosis (DVT) if the patient is on Coumadin maintenance to prevent disease recurrence. However, if a patient has a Greenfield filter, would you code history of DVT or the active disease? Either a personal history code or code for active disease may be appropriate. Query the physician for clarification. A patient with a Greenfield filter may have acute, chronic, or recurrent DVT, or the DVT may resolve over time. If the DVT has resolved, it may be reported as personal history of venous thrombosis and embolism. The patient may not have active disease but is being managed because of susceptibility for recurrence. Subacute codes to acute

PSI 13 – Postoperative Sepsis Rate
Postoperative sepsis cases (secondary diagnosis) per 1,000 elective surgical discharges for patients ages 18 years and older Excludes: Cases with a principal diagnosis of sepsis Cases with a secondary diagnosis of sepsis present on admission Cases with a principal diagnosis of infection Cases with a secondary diagnosis of infection present on admission (only if they also have a secondary diagnosis of sepsis) Obstetrics discharges Make sure physicians clarify POA, especially if clinical indicators of sepsis were present. Get any local infections documented. Potentially query whether postop sepsis refers to sepsis in the postoperative period or is a complication of the surgical procedure Drive home the importance of abstracting and elective admissions.

PSI 14 – Postoperative Wound Dehiscence Rate
Postoperative reclosures of the abdominal wall per 1,000 abdominopelvic surgery discharges for patients ages 18 years and older Excludes: Cases in which the abdominal wall reclosure occurs on or before the day of the first abdominopelvic surgery Cases with an immunocompromised state Cases with stays less than two days Obstetrics cases In ICD-10-CM, cases are included if they have a diagnosis code of disruption of internal surgical wound with a reclosure procedure

PSI 15 – Unrecognized Abdominopelvic Accidental Puncture/Laceration Rate
Accidental punctures or lacerations (secondary diagnosis) during a procedure of the abdomen or pelvis per 1,000 discharges for patients ages 18 years and older that require a second abdominopelvic procedure one or more days after the index procedure Excludes: Cases with accidental puncture or laceration as a principal diagnosis Cases with accidental puncture or laceration as a secondary diagnosis that is present on admission Obstetrics cases

Thank you. Questions? amyc@recordsone.com tom@recordsone.com
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.

Appendix

Notice, Update - Foreign Body Left During Surgery Question: While drilling one of the transosseous suture holes, during the procedure, a drill bit broke off inside the trochanter. The documentation indicates it seemed to be quite deep into the bone and was not retrievable; and as such, it was left in place. The National Quality Forum (NQF) revised information on Serious Reportable Events in Healthcare. In Appendix A, on surgical or invasive procedure events, Event 1D Unintended retention of a foreign object in a patient after surgery or other invasive procedure currently excludes objects not present prior to surgery/procedure that are intentionally left in when the risk of removal exceeds the risk of retention (such as microneedles, broken screws). In light of the NQF update, is code 998.4, Foreign body accidentally left during a procedure, still appropriate when the provider intentionally leaves a foreign body during surgery so that the patient is not subject to the added risk of removal? Answer: Do not assign code 998.4, Foreign body accidentally left during a procedure, when the provider intentionally leaves a foreign body during surgery as to not subject the patient to the additional risk of removal. Assign instead code E871.0, Foreign object left in body during procedure, surgical operation, to show that there was a problem with a foreign body left during the procedure. The advice previously published in Coding Clinic is now being updated to reflect the NQF Update. Remember that coding guidance and quality criteria don’t always match. Quality staff need to understand coding guidelines as they pertain to HACs and PSIs

Postoperative Retained Cement Fragment Question: A patient was admitted for right hip hemiarthroplasty due to femoral neck fracture. While in the post-anesthesia care unit, postoperative radiographs revealed a loose cement fragment in the joint. The patient was returned to surgery for exploration and removal of the cement fragment. What is the ICD-10-CM code assignment for the retained loose bone cement of the right hip? Answer: Assign code T81.590A, Other complication of foreign body accidentally left in body following surgical operation, Initial encounter. In ICD-10-CM, the accidental retention of a foreign body following surgery is classified as a complication. Even though there was no immediate problem resulting from the retained cement in this case, it is reported with a complication code.

Rib Fracture Due to Cardiopulmonary Resuscitation (CPR) Question: What is the diagnosis code assignment for a rib fracture due to cardiopulmonary resuscitation? Answer: Assign code , Fracture of rib(s), sternum, larynx, and trachea, rib(s), closed, rib(s), unspecified, and code E879.8, Other procedures without mention of misadventure at the time of procedure, as the cause of abnormal reaction of patient or of later complication, Other specified procedures. Fractures of the rib occurring secondary to cardiopulmonary resuscitation (CPR) efforts are not uncommon and a known risk; therefore, this would not be classified as a complication. Although the fracture is not considered a complication, the E- code is assigned to provide information about how the fracture occurred. Another example, complication code not assigned, but still a HAC.

ICD-10-CM Official Guidelines – Uncertain Diagnoses
If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” “still to be ruled out,” or other similar terms indicating uncertainty, code the condition as if it existed or was established The basis for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care, and psychiatric hospitals

Present on Admission Reporting Guidelines
These guidelines are not a substitute for the provider's clinical judgment as to the determination of whether a condition was/was not present on admission. The provider should be queried regarding issues related to the linking of signs/symptoms, timing of test results, and the timing of findings. There is no required time frame as to when a provider (per the definition of "provider" used in these guidelines) must identify or document a condition to be present on admission. In some clinical situations, it may not be possible for a provider to make a definitive diagnosis (or a condition may not be recognized or reported by the patient) for a period of time after admission. In some cases it may be several days before the provider arrives at a definitive diagnosis. This does not mean that the condition was not present on admission. Determination of whether the condition was present on admission or not will be based on the applicable POA guideline as identified in this document, or on the provider's best clinical judgment.

Present on Admission Reporting Guidelines
If at the time of code assignment the documentation is unclear as to whether a condition was present on admission or not, it is appropriate to query the provider for clarification. If the final diagnosis contains a possible, probable, suspected, or rule-out diagnosis, and this diagnosis was based on signs, symptoms, or clinical findings suspected at the time of inpatient admission.

Coding Clinic, Second Quarter 2012, p. 20
Clarification: Catheter-Associated Urinary Tract Infection (CAUTI) Question: We are seeking clarification regarding the advice previously published in Coding Clinic, Third Quarter 2009, pages 9-10, regarding the coding of catheter-associated urinary tract infection (CAUTI) when the patient has an indwelling catheter and then develops a urinary tract infection (UTI). If there is no provider documentation of CAUTI, but there is documentation that the patient has a UTI and it is noted that the patient has an indwelling catheter, can a coder automatically assign code , Infection and inflammatory reaction due to indwelling urinary catheter? Answer: No, the provider must clearly document the causal relationship. If the provider states that the UTI is secondary to the indwelling urinary catheter, assign code , Infection and inflammatory reaction due to indwelling urinary catheter, and code 599.0, Urinary tract infection, site not specified. If the provider does not state that the urinary tract infection is due to the catheter, assign only code The Official Guidelines for Coding and Reporting state, "As with all procedural or postprocedural complications, code assignment is based on the provider's documentation of the relationship between the condition and the procedure." However, considering the importance of preventing and tracking CAUTIs, if the patient has an indwelling catheter and a UTI, coders should query the provider regarding the cause of the UTI and ask that the information be documented in the record (even when the cause of the UTI is not the catheter). Physicians must be clear and document relationship or lack there of. If they are not, the query will be issued. Best practice: query should already be placed and answered before it gets to the coder. Best Practice: Have Infection prevention/control present the query to the physician. POA establishment is critical. Coders, CDS, and other staff must look at all clinical indicators. DDx in the ED also very important.

Central line–associated bloodstream infections (CLABSI), which is the current preferred terminology to describe these infections, are common, with an estimated 250,000 cases occurring in hospitals in the United States. They have been defined by the Centers for Disease Control and Prevention as laboratory- confirmed bloodstream infections (LCBI) that are not secondary to an infection at another site. These infections cause longer hospitalization and resource use.

Residual Right-Sided Weakness Due to Previous Cerebral Infarction Question: The patient is a 72-year-old male admitted to the hospital because of gastrointestinal bleeding. The provider documented that the patient had a history of acute cerebral infarction with residual right-sided weakness (dominant side), and ordered an evaluation by physical and occupational therapy. What is the appropriate code assignment for residual right-sided weakness, resulting from an old CVA without mention of hemiplegia/hemiparesis? Answer: Assign code I69.351, Hemiplegia and hemiparesis following cerebral infarction, affecting right dominant side, for the residual right-sided weakness due to cerebral infarction. When unilateral weakness is clearly documented as being associated with a stroke, it is considered synonymous with hemiparesis/hemiplegia. Unilateral weakness outside of this clear association cannot be assumed as hemiparesis/hemiplegia, unless it is associated with some other brain disorder or injury.

Coding Clinic, Third Quarter 2016, p. 38
Pressure Injury Question: Please advise how to code pressure injury in ICD-10-CM. There is no entry in the alphabetic index for pressure injury. In April 2016, the National Pressure Ulcer Advisory Panel (NPUAP) announced a change in terminology from “pressure ulcer” to “pressure injury” and also updated the stages of pressure injury. The change in terminology more accurately describes pressure injuries to both intact and ulcerated skin. In the previous staging system Stage 1 and Deep Tissue Injury described injured intact skin, while the other stages described open ulcers. This led to confusion because the definitions for each of the stages referred to the injuries as “pressure ulcers.” In light of the NPUAP redefining pressure ulcers as pressure injury, can coders assume that a documented “staged pressure injury” is assigned to the corresponding decubitus/ pressure ulcer codes? Will new index entries be created for “pressure injury” with the new code update? Answer: This is a change in terminology rather than a change in definition of pressure ulcer. For the term “pressure injury” meaning pressure ulcer, code as a pressure ulcer by the site and stage or unstageable as appropriate. The stages of pressure injury used in the NPUAP's updated terminology correspond to the pressure ulcer stages in ICD-10-CM. Therefore, code a nontraumatic pressure injury the same as a pressure ulcer by site with stages one through four and unstageable. Pressure injury, stage 1–4 would be coded as pressure ulcer, stage 1–4. A deep tissue injury is coded as an unstageable pressure ulcer. In ICD- 10-CM, there is an existing index entry under deep tissue injury to indicate there is additional material in the Coding Clinic. Note from Adam: The answer given on this slide ends in a colon, suggesting there’s more text that we’re not showing. Did the end of the answer get cut off? Should we supply whatever text is missing?

POA Indicator for Pressure Ulcer Progression Question: We understand that the ICD-10-CM codes for pressure ulcers include the location of the ulcer as well as the stage. What is the correct diagnosis code and present on admission (POA) indicator for a patient admitted to the hospital with a stage 2 pressure ulcer of the left heel that worsens during the hospitalization and becomes a stage 3 ulcer? Answer: Assign code L89.622, Pressure ulcer of left heel, stage 2, for the site and stage of the ulcer on admission. Assign code L89.623, Pressure ulcer of left heel, stage 3, for the site and highest stage of the ulcer reported during the admission. Report a POA indicator of “Y” for code L89.622, Pressure ulcer of left heel, stage 2; and a POA indicator of “N” for code L89.623, Pressure ulcer of left heel, stage 3, to reflect that the pressure ulcer was a stage 2 on admission, but progressed to stage 3 during the hospitalization. As of October 1, 2016, the ICD-10-CM Official Guidelines for Coding and Reporting have been revised to indicate that if a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned: one code for the site and stage of the ulcer on admission and a second code for the same ulcer site and the highest stage reported during the stay.

Using the X-Ray Report for Specificity
Additionally, in the inpatient setting, abnormal findings are not coded and reported unless the provider indicates their clinical significance. If the finding are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provide whether the abnormal finding should be added.

Drive Positive Impacts on PSI, HAC, and Other Value-Based Models

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