Coded data has a long and influential life span that follows patients—and those responsible for patient care—far into the future. While patient safety, quality care and reimbursement are the first things that come to mind, the significant impact of coding on the long-term financial stability and reputational standing of healthcare providers and intuitions cannot be overemphasized. 

Patient Safety Indicators (PSIs) factor significantly into the healthcare ratings used by consumers to make informed decisions about where to seek care and how to best spend their money. Payers are committed to managing their risk and offer more favorable terms to organizations that demonstrate successful outcomes and positive ratings. 

Bottom line: Consumers and payers want to do business with organizations that do a good job taking care of their patients.  This article showcases HIM’s unique role in mitigating risk associated with PSI reporting and healthcare ratings. 

The Agency for Healthcare Research and Quality (AHRQ) recently released updates to their PSI criteria for fiscal year (FY) 2021. While this update includes many important changes, we will focus specifically on PSI 08, PSI 11, and PSI 14. Changes to the calculations for these PSIs significantly increase the risk of financial and reputational damage from inaccurately coded data. 

  • PSI 08: In-Hospital Fall with Hip Fracture Rate—Patients who suffer an in-hospital hip fracture (not present on admission) no longer require a hip procedure to qualify for inclusion in this PSI calculation. Many other exclusions were removed including syncope, stroke, seizure disorders, and delirium. These changes greatly increase the reporting potential of PSI 08 and underscore the need for prevention of in-hospital falls 
  • PSI 11: Postoperative Respiratory Failure Rate—AHRQ increased the impact of PSI 11 by changing its weight in the PSI-90 composite from 16.8 percent to 24 percent and removed the exclusion for MDC 5. Since postoperative respiratory failure is commonly documented in patients following cardiothoracic surgery, accurate clinical documentation and adherence to Official Guidelines for Coding and Reporting and coding conventions in ICD-10-CM is critical 
  • PSI 14: Postoperative Wound Dehiscence Rate—AHRQ removed the exclusion for immunocompromised state, including patients with HIV disease 

Since consumer perception is largely shaped by publicly available data, such as PSI rates and various ratings methodologies, the data must be pristine before it becomes public. A comprehensive proactive audit plan designed to validate these critical data elements is key. Savvy healthcare providers and organizations keep a close watch on their PSI reporting and overall ratings and view them as an opportunity to do a deep dive into the integrity of their institutional data. This process should involve stakeholders across the continuum. Audit findings can be used to correct current deficiencies and identify opportunities to upskill team members. A few audit tips to keep in mind: 

  • Complication of Care Codes. As stated in the ICD-10-CM Official Guidelines for Coding and Reporting, it is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition and an indication in the documentation that the condition is a complication. When in doubt, query the provider for clarification. Incorrectly assigned complication of care codes can negatively impact healthcare ratings 
  • Present on Admission (POA) Indicators. “False positives” can occur in Patient Safety Indictor (PSI) rates if incorrect POA indicators are assigned. Many PSIs have a coding exception that removes those cases from the PSI algorithm if the condition was present on admission and did not develop after the admission. It is of particular importance to monitor POA indicators associated with patients who are transferred from outside facilities. The receiving facility does not want to take the hit for a PSI that occurred at the transferring facility 
  • Resolved vs. Active Conditions. Although the practice of cloned documentation (copy and paste of clinical information) in electronic health records can be a timesaver for clinicians, it can pose a risk to documentation integrity and coding accuracy. Cloned documentation has the potential to blur the distinction between current conditions and resolved (historical) conditions. If documentation of historical (resolved) conditions is misinterpreted as current conditions—and coded as such—artificially inflated PSI rates can occur 

Coding is a key element by which the quality of patient care is judged, uniquely positioning HIM professionals to showcase their broad influence in healthcare.  By partnering with organizations and providers to achieve accurate PSI reporting and improved healthcare ratings, HIM professionals can spotlight the unique skills that make them indispensable to many different areas of healthcare.  For an in-depth summary of FY 2021 PSI changes, click here.   


Daniel Land, is director of organizational learning for revenue cycle solutions at AMN Healthcare, an AHIMA21 sponsor. 


About AMN Healthcare Revenue Cycle Solutions

AMN Healthcare Revenue Cycle Solutions is the industry’s most experienced mid-revenue cycle provider. We use business intelligence and data analytics to uncover opportunities to place highly skilled professionals and improve revenue capture and savings by providing multiple, measurable benefits. As an integrated AMN solution, we deliver the most comprehensive services to help healthcare organizations succeed in a patient-centered world. 

AMN Healthcare Revenue Cycle Solutions is an AHIMA21 Supporting Sponsor