1. Patient Safety Indicators PSI AHRQ Quality Indicators evaluate in-hospital complications and adverse events following surgeries, procedures, and childbirth ages 18 years and older
Jennifer Piña, BSN, RN, CCDS
Clinical Documentation Specialist

2. Agenda Overview of PSI 90 Identify PSI 90 composite
Identify common exclusion criteria for each measure
Identify documentation opportunities to accurately reflect the correct PSI’s assigned.

3. The purpose of the PSI 90 composite measure score
PSI-90 is a composite measure that was developed to :
Monitor quality performance
Used for comparative reporting
Improvement quality care at the provider level.
Screen for complications or adverse events that patients experience as a result of exposure to the healthcare system.

4. Patient Safety Indicators?
PSIs are a set of measures that screen for complications or adverse events that patients experience inpatient in the hospital.
When hospitals report PSIs in their quality data they can carry financial consequences as part of the pay for performance initiatives.
PSIs reflect the quality of inpatient care and focus on preventing complications
Intended to identify preventable conditions and develop plans for performance improvement.
Reflect the safety climate of a hospital by providing a marker of patient safety during the delivery of care.
Can be used as a resource for patients when selecting care options, used for providers in allocating resources, and for payers in evaluating performance.

5. Measure Specifications (age 18 years and older)
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 Post-Operative 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 Accidental Puncture or Laceration Rate

6. How can CDI assist hospitals by reviewing for PSI quality data?
CDI can assist with false reporting of these PSI’s by understanding the comorbid conditions that might exclude cases from reporting CDI can query physicians to obtain proper documentation, such as if condition is inherent or an expected condition with the procedure. CDI can Identify PSI’s and help organizations address deficiencies with quality of care, and improve data quality. CDI can determine if the condition is POA and obtain clear documentation to support the POA of yes.

7. PSI # 03 Pressure ulcer
Stage III or IV pressure ulcers or unstageable (secondary diagnosis) that are not present on admission (POA)

8. Exclusions for PSI 03 Pressure ulcer
Length of stay less than 3 day A principal diagnosis of stage III or IV (or unstageable) pressure ulcer diagnosis A secondary diagnosis of stage III or IV pressure ulcer (or unstageable) that is present on admission severe burns Exfoliative skin disorders

9. Helpful tips for CDI?
PSI 03 pressure ulcer
Common questions What if the patient was admitted with a pressure ulcer and it progresses to a higher stage? Two separate codes are assigned for each stage. If the higher stage is a PSI not POA, CDI should review nursing notes, wound care notes clarify if the staging is correct and if it was present on admission.

10. Helpful tips for CDI?
PSI 03 pressure ulcer
What if a deep tissue injury (DTI) is documented not POA, is this considered a PSI? Yes, the DTI (Deep tissue injury) will code to an unstageable pressure ulcer. CDI should review assessments to determine if a query is needed for the POA status.
The stages of pressure injury used in the NPUAP's updated terminology correspond to the pressure ulcer stages in ICD-10-CM. Pressure injury, stage 1-4 would be coded as pressure ulcer, stage A deep tissue injury is coded as an unstageable pressure ulcer.
Copyright (2019), American Hospital Association ("AHA"), Chicago, Illinois. Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.

11. PSI 06 Iatrogenic Pneumothorax
Iatrogenic pneumothorax cases as a (secondary diagnosis) for surgical and medical discharges.
ICD 10 code that triggers PSI #6 J Postprocedural pneumothorax

12. Exclusions for PSI 06 Iatrogenic pneumothorax
chest trauma
 pleural effusion
 thoracic surgery
 lung or pleural biopsy
 diaphragmatic repair
 cardiac procedures
 A principal diagnosis of iatrogenic pneumothorax
A secondary diagnosis of iatrogenic pneumothorax present on admission

13. PSI 06 Iatrogenic pneumothorax
Helpful tips for CDI?
PSI 06 Iatrogenic pneumothorax
Look for clinical evidence to evaluate if the pneumothorax is spontaneous or due to an underlying condition, disease or injury vs. caused by medical intervention (iatrogenic). If clinically indicated, seek clarification if the pneumothorax may be the result of an underlying clinical condition. When something is routinely expected after a procedure, the MD should make that clear in their documentation. Example: "expected pneumothorax with air leak" or "inherent to the procedure"
Example:  Patient developed a left pneumothorax after a TAVR procedure.    During the procedure the patient required vascular intervention.  Since the patient had a cardiac surgery the pneumothorax is considered excluded.  

14. In hospital fall with hip fracture as a (secondary diagnosis)
PSI 08 In-Hospital Fall with Hip Fracture Rate
In hospital fall with hip fracture as a (secondary diagnosis)

15. Exclusions for PSI 08 In-Hospital Fall
with Hip Fracture Rate
Must be the Principle Diagnosis to Exclude: Coma in DM and Hepatic disease Seizure Syncope Stroke Poisoning Cardiac arrest Delirium and other psychoses (includes dementia) Metastatic cancer Bone or lymphoid malignancy 

16. PSI 08 In-Hospital Fall with Hip Fracture Rate
Helpful tips for CDI?
PSI 08 In-Hospital Fall with Hip Fracture Rate
If clinically appropriate, clarify for "Excluded" diagnoses listed and any of these secondary diagnosis: Look for conditions that make them susceptible to falling and conditions associated with fragile bones. Most common Lymphoma, Leukemia, and Multiple Myeloma, including cases in remission Bone malignancy Metastatic malignancy Note: Encephalopathy is not excluded.

17. PSI 09 - Perioperative Hemorrhage or Hematoma Rate
Perioperative hemorrhage or hematoma cases involving a procedure to treat the hemorrhage or hematoma, following surgery
PSI 09 Requires 2 Codes:  a Diagnosis Code,  and Procedure Code   
It becomes a PSI is when the Procedure is performed

18. Exclusions for PSI 09 Perioperative Hemorrhage or Hematoma Rate
Coagulation disorders such as thrombocytopenia, DIC, Von Willebrands disease can exclude patient from this PSI.

19. Helpful tips for CDI? PSI 09 Perioperative Hemorrhage or Hematoma Rate
There must be a procedure to control the hemorrhage or remove the hematoma to qualify.
Sometimes miscoded when a hemorrhage or hematoma occurs during the operation rather than after the operation.
Look carefully for an opportunity to link the bleeding to the therapeutic use of anticoagulants (D68.32) for an exclusion
Some procedures inherently have large volumes of expected blood loss
If operative or postoperative procedure notes do not clearly describe the circumstances of the hemorrhage or hematoma clarify with the physician if it is routinely expected or inherent to the procedure.  

20. Query Example: PSI 9 (Postoperative Hemorrhage or Hematoma) 5/6 -Hematoma was noted postoperatively and she required re-intubation and relief of hematoma. 5/6 at 1428 surgery note (post op dx s/p total thyroidectomy with post op bleed   If possible would you please further clarify if the post op bleed/hematoma was: [ ] An expected occurrence for the procedure performed ________________________________ [ ] Inherent occurrence in the surgical procedure________________________________ [ ] Complication of the procedure [ ] Other please specify:___________________________________________________________ [ ] Unable to determine

21. PSI 10 Post-Operative Acute Kidney Injury Requiring Dialysis
New onset Acute Kidney Failure which occurs after an elective surgery that requires dialysis.

22. Exclusions PSI 10 Post-Operative Acute Kidney Injury Requiring Dialysis Rate
Acute Kidney Failure as the Principal Diagnosis Acute kidney Failure documented to be present on admission (POA) Cases with acute kidney failure and cardiac arrhythmia, cardiac arrest, shock, urinary tract obstruction or chronic kidney failure;

23. PSI 10 Post-Operative Acute Kidney Injury Requiring Dialysis Rate
Helpful tips for CDI?
PSI 10 Post-Operative Acute Kidney Injury Requiring Dialysis Rate
If this condition develops after surgery, it only counts against PSI #10 if patient needs dialysis.

24. PSI 11 Postoperative Respiratory Failure
Postoperative respiratory failure as a (secondary diagnosis), prolonged mechanical ventilation, or reintubation cases. Acute Respiratory Failure Following Surgery and Postoperative respiratory failure should only be documented if the reason for prolonged mechanical ventilation is directly related to the surgery itself.

25. PSI 11 Postoperative Respiratory Failure
“Prolonged mechanical ventilation” should be defined based on your institutional norms, but should only be considered if the patient remains ventilated for more than 48 hours after surgery Should not use postop respiratory failure if the patient did not remain on the ventilator longer than would typically be expected for the surgery or procedure performed.

26. Exclusions for PSI 11 post op respiratory failure
Procedure for laryngeal or pharyngeal, nose, mouth, pharynx or facial surgery
Diagnosis for neuromuscular disorder
Procedure codes for esophageal resection
Procedure codes for lung cancer pleural biopsy, or diaphragmatic surgery repair.
Diagnosis for degenerative neurological disorder
Procedure codes for lung transplant
MDC 4 (diseases/disorders of respiratory system)
MDC 5 (diseases/disorders of circulatory system)

27. Helpful tips for CDI? PSI 11 Postoperative Respiratory Failure
Do not code as post‐op or post‐procedural unless the MD documents that way.
Only a PSI for elective surgeries.
Prolonged ventilation is expected with certain procedures and pre-existing conditions. (Query physician prolonged ventilation secondary to condition Ex. severe COPD, CHF )
If clinically supported, clarify for:
Acute Pulmonary Insufficiency (due to underlying pulmonary disease and NOT a complication of surgery)

28. PSI 12 Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate
Perioperative pulmonary embolism or proximal deep vein thrombosis as a (secondary diagnosis) for surgical patients.

29. Exclusions for PSI 12 Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate
where a procedure for interruption of vena cava occurs before or on the same day as the first operating room procedure
where the only operating room procedure was for the interruption of the vena cava
diagnosis code present on admission for acute brain or spinal injury
procedure code for extracorporeal membrane oxygenation (ECMO)
where the only operating room procedure was for pulmonary arterial thrombectomy

30. Helpful tips for CDI? PSI 12 Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate
Look at your Doppler report to determine if the DVT was in fact in the proximal vein. (Distal versus proximal distinction)
*Distal vein DVT is not PSI 12
A popliteal vein DVT is a considered a proximal DVT and is a PSI 12.
Isolated calf vein DVT was removed from the PSI list. Isolated calf vein DVT events are more likely to be detected during screening and are often clinically insignificant events.
(upper extremity DVTs are not reported).

31. Helpful tips for CDI? PSI 12 Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate
Venous embolism will default to “acute” . May need to query physician if clinical indication is there for a chronic condition. “Superficial Embolism” “may be mistakenly coded as deep embolism” Look for diagnoses preventing the patient from being anti‐coagulated such as head bleed, acute brain injury, or spinal injury as these diagnoses may exclude patient from this PSI.

32. PSI 13 Postoperative Sepsis Rate
Postoperative sepsis cases as a (secondary diagnosis) for elective surgical discharges

33. Exclusions for PSI 13 Postoperative Sepsis Rate
Principle diagnosis Sepsis or secondary diagnosis that was POA Principle diagnosis of infection present on admission Cases with an immunocompromised state, cases with cancer, obstetric discharges, and cases with stays less than four days.

34. for PSI 13 Postoperative Sepsis Rate
Helpful tips for CDI
for PSI 13 Postoperative Sepsis Rate
*Remember only on Elective procedures If clinically appropriate clarify for POA status of any infection and evaluate if it was present on admission   Was the patient immunocompromised?

35. PSI 14 Postoperative Wound Dehiscence Rate
Postoperative reclosures of the abdominal wall with a diagnosis of disruption of internal operational wound for abdominopelvic surgery ICD-10-CM Code that Triggers PSI 14: T8132XA  Disruption of internal operation (surgical) wound (NOT POA) ICD-10-PCS Codes that Trigger PSI 14:  Reclosure of postoperative disruption of the abdominal wall procedure codes: (Extensive list, not displayed)

36. Exclusions for PSI 14 Postoperative Wound Dehiscence Rate
If the disruption of internal operation wound is present on admission
Immunocompromised state
Length of stay less than 2 days

37. PSI 14 Postoperative Wound Dehiscence Rate
Helpful Tips for CDI
PSI 14 Postoperative Wound Dehiscence Rate
If clinically appropriate query for "immunocompromised state diagnoses" (not all inclusive)         HIV and other immunodeficiency syndromes ESRD Severe Malnutrition Neutropenia Transplant status (organ, tissue, stem cell, bone marrow, bone graft) Myelodysplastic disease Graft vs. Host disease Pancytopenia, drug induced, due to chemo Agranulocytosis, drug induced, due to chemo

38. PSI 15 Unrecognized Accidental Puncture or Laceration Rate
Accidental punctures or lacerations as a (secondary diagnosis) during a procedure of the abdomen or pelvis that require a second abdominopelvic procedure one or more days after the procedure.

39. Exclusions for PSI 15 Unrecognized Accidental Puncture or Laceration Rate
Obstetric cases
• Cases with an accidental puncture or laceration that is present on admission such as a patient returning to the hospital after discharge from a recent surgical procedure.

40. PSI 15 Unrecognized Accidental Puncture or Laceration Rate
Helpful Tips for CDI
PSI 15 Unrecognized Accidental Puncture or Laceration Rate
*Remember to be a PSI 15, the patient must return to the OR for a second abdominopelvic procedure *Terms that suggests non-accidental puncture or laceration:   To facilitate Necessary   Required Intentional Intended Inherent   Integral Routinely expected   *Documentation should distinguish between accidental punctures and lacerations that are inherent to the procedure and those that considered a complication.

41. Query the provider for clarification, if the complication is not clearly documented.
Example: Please check appropriate box(s):   In the description of the operative procedure (a concern for perforation) was noted by the surgeon.  If possible would you please further clarify if this was:   [ ] Incidental occurrence inherent in the surgical procedure [ ] Complication of the procedure [ ] Other ___________ [ ] Unable to determine

42. POA indicator reporting Options
Tip: If physician responds to a query clinically unable to determine, use W indicator for POA indicator. This will remove the PSI or HAC.

43. Check if it was a nonelective surgical admissions
Check if it was a nonelective surgical admissions. Some surgical PSIs are only applicable to elective surgeries.
PSI 11: Postoperative Respiratory Failure
PSI 13: Postoperative Sepsis.
If a patient safety event occurs after a nonelective surgery, this case may be mistakenly included in the rate and would incorrectly inflate the rate.

44. Sources: Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators Overview   CMS Measures Inventory Tool: PSI 90 (August 2018)   AHRQ PSI 90 Fact Sheet