I previously discussed how selection of principal diagnosis may impact quality. This ripple effect (like a pebble on a pond) may occur when one works in a silo, ignoring other departments such as quality. If only the ripple effect was the lone “offender” in which CDI and coding may impact quality outcomes. Consider a spider web: intricately designed and seeming impervious. However, as strands get broken, the web collapses.
In review, CDI professionals and coders are tasked with obtaining and capturing a complete picture of the patient’s encounter for appropriate reimbursement, accurate reflection of severity of illness (SOI) and risk of mortality (ROM) and outcomes of care. Historical models of CDI programs and coding processes focused predominately on the first two tasks, without acknowledgement of how this may affect quality outcomes (potentially fracturing the spider web).
But what if improving reimbursement and SOI and ROM actively damages the quality scores of your institution? Case in point, a patient undergoing surgery has oxygenation issues postoperatively, requiring higher levels of oxygen support for a couple of days, but never needing any ventilatory support (invasive or non-invasive). Based on coding directives, documentation of acute respiratory failure or acute respiratory distress following surgery provides increased reimbursement and higher SOI and ROM for the case. Win-win, right? Not so much. We dropped a great big pebble in the lake, but shattered that quality spider web lying over it.
The Agency for Healthcare Research & Quality (AHRQ) developed patient safety indicators (PSIs), a set of metrics to evaluate and improve patient care and outcomes. They are now part of an effort by CMS to incentivize hospitals to improve their quality of care via value-based purchasing (VBP). VBP has evolved and is now expanding in FY 2015 to include a composite PSI performance score, or PSI 90. One of the PSIs included in this composite score is PSI 11, postoperative respiratory failure. Documentation of acute respiratory distress will not in and of itself qualify the case as reportable under PSI 11, but acute respiratory failure will.
So what is the correct way to handle this? Is it to only get the providers to document acute respiratory distress (and potentially under report quality issues) or let the providers document whatever they want and let the chips fall where they may? I propose option C: development of standard definitions of acute respiratory distress and acute respiratory failure (for all patients regardless of whether the patient had surgery) for consistent and compliant documentation and reporting. Only with all players openly and honestly documenting and reporting outcomes can healthcare improve. Finding ways to “beat the system” may help the hospital in the short term but is it helping the patient in the long term (or future patients)? HIM and CDI have to work together with Quality in a transparent and ethical manner as the pebble and the spider web are permanently and intricately connected.
Cheryl Manchenton is a Senior Inpatient Consultant and Project Manager for 3M Health Information Systems