This is the fourth and final article in the Patient Safety Indicator (PSI) 90 series.
Educating coders and clinical documentation improvement (CDI) specialists on CMS claims-based measures is essential in today’s value-based payment environment. Empowered with an understanding of measure specifications and risk adjustment methodologies, a strong CDI program can effectively address opportunities to improve quality profiles and associated hospital revenue.
In this series, we have provided an overview of the PSI 90 composite measure, and focused on common documentation and/or code assignment vulnerabilities associated with two of the eight PSIs in the composite: PSI 15 (Accidental Puncture/Laceration) and PSI 7 (Central Venous Catheter Blood Stream Infections). We now continue our exploration with a review of PSI 12.
Introduction to PSI 12
PSI 12 evaluates the hospital’s risk adjusted rate of perioperative deep vein thrombosis (DVT) and/or pulmonary embolism (PE) in surgical discharges for patients 18 years and older. Performance for PSI 12 contributes 25.8% of the PSI 90 composite score under the Hospital-Acquired Condition Reduction Program. Data quality issues associated with measure inclusions, exclusions and risk adjustment variables contribute to suboptimal performance. PSI 12 technical specifications and information on the risk adjustment methodology can be found at www.qualitynet.org.
PSI 12 inclusions
Discharges included in this measure are those with a secondary diagnosis that is not present on admission (POA) for one of the following conditions:
- Acute DVT of the lower extremity
- Phlebitis/thrombophlebitis of the deep vessels of the lower extremity
- Pulmonary embolus
Coding and documentation vulnerabilities for inclusions:
Perform a review of the coding classification system, coding guidelines, and clinical documentation challenges associated with these ICD-9-CM codes to identify opportunities to improve data quality. Consider the following for DVT:
- Acute DVT of the lower extremity triggers inclusion of a discharge in the measure.
- DVTs can be classified in the ICD-9-CM coding system as acute, chronic, or personal history.
Challenges with the translation of provider documentation to the correct ICD-9-CM code include:
- Documentation of “DVT” results in assignment of the code for “acute DVT;” physicians don’t need to document the word “acute.”
- Documentation of “subacute DVT” is assigned the code for an acute DVT.
- Documentation of “Past Medical History DVT” may mean that a patient has a history of a DVT, or a chronic DVT. Chronic DVT (which is a MS-DRG CC) cannot be assigned unless the physician documents “chronic DVT.”
- Providers vary in how they qualify acuity of a DVT.
PSI 12 risk adjustment
Hospital performance for PSI 90 is determined by risk adjusted performance not by the actual (or observed) number of discharges with a peri-operative DVT and/or PE. Agency for Healthcare Research and Quality (AHRQ) comorbidity software identifies the presence or absence of defined risk adjustment variables, each of which has a coefficient weight. These risk adjustment variables are critical inputs in the calculation of the hospital’s predicted events, and thus the risk adjustment calculation.
Twenty-two comorbid categories impact PSI 12 risk adjustment. Fourteen of these categories have a positive risk adjustment impact. Examples of categories with positive risk adjustment impact include:
- Pulmonary circulation disease (PULMCIRC)
- Metastatic cancer (METS)
- Weight loss (WGHTLOSS)
- Paralysis (PARA)
- Solid tumor without metastasis (TUMOR)
- Chronic blood loss anemia (BLDLOSS)
- Lymphoma (LYMPH)
- Obesity (OBESE)
- AIDS
The capture of diagnosis codes that map to the categories noted above will improve the risk adjustment for each discharge by 57%. The comorbid category PULMCIRC has a much greater risk adjustment impact on each discharge than any of the other comorbid categories.
Documentation and coding vulnerabilities
To optimize risk adjustment, coders must report one ICD-9-CM code for each comorbid category. A review of the ICD-9-CM codes that map to each comorbid category will reveal a voluminous number of codes. The purpose of the review should be to identify the most likely conditions that may be present in most discharges, as well as those conditions that require the lowest documentation specificity for impactful code assignment. The resulting list of codes can serve as a checklist to support:
- Concurrent, retrospective, prebill, and/or post-bill validation process
- Electronic health record (EHR) design and build
- Provider education
Let’s take a look at some examples of coding and documentation vulnerabilities pertinent to risk adjustment for the comorbid category PULMCIRC.
- Diagnoses that map to this comorbid category include:
- Pulmonary hypertension
- Cor pulmonale (chronic)
- Pulmonary embolus
Pulmonary hypertension is often noted in echocardiogram results. If providers copy and paste echocardiogram results into their notes, but do not document the diagnosis, coders will not assign an ICD-9-CM code for the condition.
Cor pulmonale is an outdated term that physicians rarely document. Providers need to either document “cor pulmonale” or “chronic cardiopulmonary disease” in order for coders to assign the ICD-9-CM code.
“Chronic PE” impacts risk adjustment, however “personal history of PE” does not. As discussed above with DVTs, clinical definitions to consistently qualify a PE as “chronic” is a common clinical documentation challenge.
Leveraging the EHR
EHR deployment has opened the door to numerous opportunities to enhance and standardize provider documentation. CDI specialists, who are knowledgeable of current documentation habits and common issues, can help initiate meaningful documentation-related enhancements if armed with a basic understanding the EHR and the processes that must be followed to turn enhancement requests into a reality.
Identify the need for template changes
The first step in leveraging the EHR to drive documentation improvement initiatives involves prioritizing a list of potential EHR-based modifications. Identify the diagnoses/conditions or clinicians who consistently require intervention and consider the impact that initiatives such as ICD-10 and risk-adjustment based quality measures such as PSI 90 will have on your organization.
In the case of PSI 12, which encompasses perioperative DVT and/or PE in surgical discharges, the documentation vulnerabilities described above can be alleviated by minor enhancements to the EHR. To improve the capture of comorbidities with the goal of obtaining optimal risk adjustment for PSI 12, the EHR can be configured to:
- Present a point-and-click form or pick list of common comorbidities for pre-surgical patients
- Dynamically prompt for additional specificity related to conditions during note composition
- Integrate documentation templates with the patient’s past medical history and problem list
EHR functionality related to documentation prompts, in particular, presents a significant opportunity for improving and streamlining the capture of diagnostic specificity within a variety of provider templates, such as:
- History and physical notes
- Consult notes
- Progress notes
- Pre-anesthesia notes
- Discharge summary
- Nutrition notes
- Wound care notes
- Death note
How to get involved
Depending on the size of your organization, your EHR will have anywhere from a single person to a large team supporting the system. These individuals are responsible for supporting end-user issues, facilitating system upgrades, and managing enhancement requests. With larger EHR systems, IT staff are responsible for supporting individual areas such as HIM, radiology, surgery, etc.
Your IT department will have a process in place for submitting enhancement requests that are then distributed to the appropriate team. Begin by following the enhancement request process. Submit change requests as early as possible to allow the IT department enough time to evaluate, build, and deploy the enhancements. When requesting a change, make sure to include as much information as possible, such as:
- Requesting physician name
- Requesting physician specialty
- Documentation tool/template name
- Specific location of tool/template to change
- Suggested changes the tools/templates
When possible, also include screenshots or examples.
If you are unfamiliar with the tools or templates that providers use to create notes in the EHR, ask the provider directly or reach out to the training/IT team for more information.
Find partners
As the industry becomes more transparent by publishing rankings, severity of illness/risk of mortality scores, and other core measure data points, organizations are becoming increasingly aware of the importance of documentation. Potential partners during EHR documentation improvement initiatives include:
- Finance
- Quality
- Physician advisor to CDI
- Chief medical information officer
Each group or individual listed above is interested in different aspects of provider documentation in the EHR and may be interested in reviewing or being a part of the request process. When approaching these different individuals or groups you need to find a balance between the perspective of finance and quality and that of physicians – striking this balance is critical to successfully deploying EHR changes. Your organization may also have a data governance or optimization program in place and your CDI staff should consider joining these groups or, at the very least, begin actively providing feedback to them.
While every EHR is different, all contain structured documentation tools that can be modified to facilitate the capture of specificity related to CDI efforts. To take full advantage of the EHR, a powerful enabler for documentation improvement, it is critical to get a seat at the table for discussions regarding optimization of your EHR.
Summary
CDI programs are chartered to improve documentation and code assignment pertinent to defined organizational objectives. Your organization’s leadership is likely unaware of the impact that documentation and code assignment have on claims based quality measures such as PSI 90, mortality, complications, efficiency, and readmissions. We hope the information in this series of articles empowers you with examples of how your CDI specialists and coders can impact claims-based measures, and that you seize the opportunity to get engaged.
Editor's note: Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer, is a director with CCDI-DQ. Newell provides consulting services to hospitals interested in strengthening their coding and CDI programs to support accurate, optimal DRG assignment and claims-based quality outcomes such as those measured by CMS P4P programs. She specializes in building sustainable programs designed to identify and address organizational priorities for documentation and coding improvement. You can reach Newell at (704) 931-8537 or sknewell1010@gmail.com.
Steve Weichhand and Sean Johnson lead the provider documentation improvement service line at Falcon Consulting Group. Falcon Consulting is an EHR consultancy specializing in EHR planning, implementation, optimization, and support. Weichhand and Johnson are both former Epic employees with years of technical experience, and their service line has been proven to improve physician efficiency, enhance documentation specificity, and create a structured process for future optimization. For inquiries, call (312) 751-8900 and ask for Steve or Sean. Email Steve at steve.weichhand@falconconsulting.com. Email Sean at sean.johnson@falconconsulting.com.