Coding, Classification & Reimbursement

HAC/PSI Issue

  • 1.  HAC/PSI Issue

    Posted 03-13-2018 14:17
    Like many hospitals, we've geared our reviews for HACs/PSI to avoid the penalties which may come along with them, but we're running into a few issues that I wonder if anyone else is coming up with and/or how you may get around it?

    The other day he had a case get coded with a rib fracture with a POA N.  The patient's rib was fractured administering CPR.  Not sure how to work with that case when it is technically true the patient's rib fracture occurred in-house, it's also true that given the condition, it's not unexpected.

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    Seth Katz
    Associate Administrator, Information Management
    Truman Medical Center
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  • 2.  RE: HAC/PSI Issue

    Posted 03-14-2018 07:58
    ​Hello!

    Please see Coding Clinic, 1st QTR 2013, Page 15.

    "Question:
    What is the diagnosis code assignment for a rib fracture due to cardiopulmonary resuscitation?

    Answer:
    Assign code 807.00, 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. "

    I am not aware of any subsequent, superseding advice.  Of course, you would use the appropriate corresponding ICD-10 codes.



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    Lawrence Barr
    President
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  • 3.  RE: HAC/PSI Issue

    Posted 03-14-2018 09:41
    Dear Seth,

    What do you mean by in-house? Can you please be more specific? Also are you sure that this was the first time that the patient had CPR performed? Meaning did the paramedics or someone at home perform CPR before the patient came to the hospital?

    All this information is pertinent when deciding on POA.

    Jodi Miller, RHIT, CCS

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    Jodi Miller, RHIT, CCS
    Outpatient Coder/Abstractor
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  • 4.  RE: HAC/PSI Issue

    Posted 03-14-2018 10:58

    No, wasn't done in the ambulance.

     

    We've really had some struggles on the whole PSI thing.  We've also had issues with PSI-11, Postoperative Respiratory Failure Rate, and the cases that occur as a result of a code blue situation?  An intubation procedure is picked up by coders, and there is NO exclusion for post procedure intubation in respiratory or cardiac arrest. 

     

    Best Doctors in Kansas City

    University Health

    SETH JEREMY KATZ, MPH, RHIA, FAHIMA
    Associate Administrator, Information Management
    (816) 404-3355 | seth.katz@tmcmed.org

    UMKC Health Sciences District

     

     






  • 5.  RE: HAC/PSI Issue

    Posted 03-15-2018 09:54
    Dear Seth,

    If CPR was not done in the ambulance, was it done at home by anyone such as a family member, bystander, EMS?

    Jodi Miller, RHIT, CCS

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    Jodi Miller, RHIT, CCS
    Outpatient Coder/Abstractor
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  • 6.  RE: HAC/PSI Issue

    Posted 03-15-2018 15:26
    ​Unfortunately it is reportable if it meets UHDDS. If nothing is done about it , we don't code. If nerve block given, or consult done to assess pain, or some other intervention done, then it is reported. Often I see cases where it doesn't meet UHDDS and is incidental finding on CXR.

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    Lori Sommervold, RHIA,BS
    Inpatient Coding Coordinator
    Froedtert Hospital
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  • 7.  RE: HAC/PSI Issue

    Posted 23 days ago
    Hi Seth,
     Thank you for posting on this issue of PSI. I'd love to connect with you and talk thru some of the ways we are working with reporting these but we too are struggling with capturing PSI's that don't seem to accurately reflect the true intent of the reason we started reporting out on patient safety indicators.

      We have a specific PSI issue currently we are addressing with our Physician Advisor and the Wound Care department as it relates to PSI 03 Pressure Ulcers. The wound care department has been given guidance that they should document "deep tissue injury" by the NPUAP (The National Pressure Ulcer Advisory Panel) for any intact skin. Unfortunately, we have a conflict with Coding Clinic guidance to code "deep tissue injury" to a pressure ulcer, hence qualifying these cases as a PSI. It's pretty clear by some of the documentation we've seen that the patient had a bruise (that could result in a wound that's stageable) but I don't think that was the intent of Coding Clinic.

    I'd really love to continue networking on a solution for this.
    Thanks,
    Shawn

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    Shawn Armbruster, RHIA
    Director, Coding & CDI
    Hurley Medical Center
    sarmbru1@hurleymc.com
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  • 8.  RE: HAC/PSI Issue

    Posted 22 days ago
    ​We have experience this same HAC as well.   We have discussed this in depth with our multi-disciplinary HAC committee.  Please reach out to me if you would like to discuss this any further.

    Thank you,
    Amy McGowan, RHIT, CCS

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    Amy McGowan, RHIT, CCS
    Inpatient Coding Auditor
    New Hanover Regional Medical Center
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  • 9.  RE: HAC/PSI Issue

    Posted 21 days ago
    ​Hello!

    Just because a case qualifies for a HAC/PSI review does not mean a facility provided inadequate care.  Rib fractures due to CPR should really not be flagged, but they are.  As long as the patient was in cardiac arrest, the CPR had to be administered and rib fractures are a common "complication".  As a person who sometime ago administered chest compressions quite a few times I knew I fractured the patient's ribs after the first compression or two.  You can feel it and hear it.  There is nothing anyone can do about it.  I had a CPR certification card and was covered by "good Samaritan laws".

    I would find it hard to believe the fractures were not diagnosed with a chest x-ray, required additional analgesics or required increased nursing care."  Turning a patient with rib fractures in order to prevent decubiti adds to the nursing care.

    Frankly, I would consider it more wrong to not assign a code that meets UHDDS criteria with of POA = "N" in order to avoid HAAC review.  I find it hard to believe a HAC reviewer would find fault with a patient experiencing rib fractures due to CPR.  To reiterate, just because a record flags for HAC review does not mean something wrong occurred.  In-house HAC pre-bill reviewers should be aware of this.

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    Lawrence Barr
    President
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  • 10.  RE: HAC/PSI Issue

    Posted 18 days ago

    You make great points Lawrence, but where I think the concern comes from is that when looking at a hospital's data set (hospital compare, Vizient, Leapfrog, etc.) and you see HAC's or PSI's or whatever, most people don't look at it and use the same logic that you provided below.  They might look at the number and say, "Man they have a lot of hospital acquired conditions, they have poor quality."  The aggregate data doesn't really distinguish between HAC's that are expected in the course of treatment and those were a broken process or some level of negligence led to a poor outcome. 

     

    Best Doctors in Kansas City

    University Health

    SETH JEREMY KATZ, MPH, RHIA, FAHIMA
    Associate Administrator, Information Management
    (816) 404-3355 | seth.katz@tmcmed.org

    UMKC Health Sciences District

     

     






  • 11.  RE: HAC/PSI Issue

    Posted 16 days ago
    Edited by Chrystel Barron 16 days ago
    I agree with Lawrence 100%.
    At my facility, we always assign a code for the rib fractures due to CPR that occur during the hospital stay with the POA N.

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    Chrystel Barron
    Coding Education Instructor
    Cleveland Clinic Health System
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  • 12.  RE: HAC/PSI Issue

    Posted 15 days ago
    Edited by Judy Bielby 15 days ago
    Have you shared your concerns with CMS?  For example, you can find the email address hacfeedback@cms.hhs.gov at  ICD-10 HAC List - Centers for Medicare & Medicaid Services
    That would not be the only step I would take, but it is just an example of one avenue to pursue.  I think it is always important to follow the coding conventions, rules, and guidelines.  Consistent application of the requirements is key for reliable data reporting.  However, if there is a requirement that is problematic, steps should be taken to address that.

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    Judy Bielby
    Clinical Assistant Professor
    University of Kansas Medical Center
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