Clinical documentation improvement (CDI) specialists may or may not realize that the data they review and collect daily can have a significant impact on patient safety and quality scores. “The CDI folks have data that is so potentially valuable to the quality folks on a real-time basis,” says Jonathan Elion, MD, CEO of ChartWise Medical Systems. “The CDI professionals are out there every day in the charts looking for and mining the data that the quality professionals need.”
Consider the following strategies to ensure more accurate quality and safety scores:
• Ensure the correct capture of the present-on-admission (POA) indicator. Because it indicates whether a patient presented with a diagnosis or developed that diagnosis after admission, the POA indicator plays an important role in patient safety scores. If the POA indicator is not coded properly, the patient safety indicator (PSI) rate can be artificially inflated. CDI specialists must pay close attention to POA documentation for pressure ulcers, central venous catheter-related bloodstream infections, and deep vein thrombosis. Cases in which patients are transferred from another facility also must be properly documented.
• Review the record for coding integrity. For example, if an intentional procedure (eg, a laceration of plaque) is incorrectly coded as an accidental puncture or laceration (PSI 15), a CDI specialist must bring this to the coder’s attention. Also ensure that any diagnoses that could trigger a PSI actually occurred and were not ruled out. For example, rule out pneumothorax must not be coded as an actual pneumothorax.
• Ensure coding specificity. When reviewing documentation for surgeries, any events that occur after admission but prior to surgery must be documented thoroughly to avoid being incorrectly labeled as a postoperative complication or event. Pay close attention to PSI 4 (death among surgical inpatients with serious treatable complications), PSI 7 (central venous catheter-related bloodstream infection), PSI 13 (postoperative sepsis), and PSI 9 (postoperative hemorrhage or hematoma).
• Don’t stop at the first complication and comorbidity (CC) or major CC (MCC). Instead, Elion says CDI specialists must capture all relevant CCs and MCCs regardless of their impact on reimbursement because this information affects severity of illness and risk of mortality, both of which can explain poor outcomes.
Laurie Prescott, RN, MSN, CCDS, CDIP, a CDI education specialist at HCPro, says severity of illness and risk of mortality greatly affect the observed vs. expected death rate, which is often a more accurate measure of quality of care. “If we get the documentation that captures a higher severity of illness, that equates to a higher risk of mortality,” she says, adding that organizations must consider these data going forward as value-based purchasing initiatives continue to grow and more patients choose a provider based on comparative data. This issue also is important when assigning chronic conditions or CCs to patients who expire. Organizations that don’t assign these diagnoses can inadvertently inflate PSI 2 (death in low mortality diagnosis-related group). For more documentation and coding issues pertaining to each patient safety indicator, refer to tables 1 and 2 of the Agency for Healthcare Research and Quality’s “Documentation and Coding for Patient Safety Indicators” atwww.ahrq.gov/professionals/systems/hospital/qitoolkit/b4-documentationcoding.pdf.
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