Medicare, Blue Cross Blue Shield of Michigan and other third party payors will reduce hospital reimbursement when certain hospital-acquired conditions occur in the inpatient setting. They will use diagnosis codes from hospital billing data to identify these conditions.
To help us effectively manage under this new reimbursement rule, we’ve developed this reporting system, the Patient Safety Initiative – Case Review System (PSI-CRS),that will identify adverse events from diagnosis codes recorded in our hospital billing system and refer them to the appropriate faculty for investigation. Our system will help us evaluate the accuracy of the coded diagnoses and determine whether a confirmed adverse event could have been prevented. It will serve as a tool to improve coding and patient safety and reduce our exposure to financial penalties.
The PSI – CRS will identify the following adverse events, a large subset of which is being targeted by Medicare and BCBSM. Some of these events will be reviewed by Infection Control, Nursing or Risk Management and the others (the ones marked by an asterisk) will be referred to a physician reviewer from the clinical service where the event occurred.
• Object left in during surgery
• Air embolism
• Blood incompatibility
• Pressure ulcer (stage III or IV)
• Falls and trauma (fracture, joint dislocation, head injury, crushing injury, burn, electric shock)
• Catheter-associated urinary tract infection
• Vascular catheter-associated bloodstream infection
• Manifestations of poor glycemic control (diabetic ketoacidosis / hyperosmolarity) *
• Manifestations of poor glycemic control (hypoglycemic coma in non-diabetics) *
• Mediastinitis after coronary artery bypass graft (CABG) *
• Surgical site infection following certain orthopaedic procedures *
• Surgical site infection following bariatric surgery *
• Surgical site infection following cardiac implantable electronic device (CIED) *
• Deep vein thrombosis and pulmonary embolism following certain orthopedic procedures *
• Iatrogenic pneumothorax with venous catheterization*
• Postoperative pulmonary embolism or deep vein thrombosis *
• Pulmonary embolism or deep vein thrombosis (for non-surgical patients) *
• Postoperative hemorrhage / hematoma * (identifies only patients who required a surgical intervention to control bleeding)
• Postoperative wound dehiscence * (identifies only patients who required a surgical intervention to close wound)
• Iatrogenic pneumothorax *
• Accidental puncture / laceration *
• Death in low mortality DRGs (adults only) (death for patients classified to a DRG that is associated with a very low mortality rate)
Several other adverse events are being tested to determine whether they are valid and useful.
How does it work?
The process that the PSI- CRS supports is illustrated as follows:
a. After a patient is discharged, Health Information Management (HIM) coding experts review medical records and assign ICD-9-CM diagnosis codes, present on admission (PoA) codes that indicate whether the diagnosis was present on admission (PoA = Y) or acquired during hospitalization (PoA = N) and other information that is necessary to submit a hospital bill. Soon after the coding is complete, the data are screened for important adverse events.
b. When an inpatient case is flagged as having an adverse event, it is referred for clinical review. You, as a primary reviewer are alerted to the presence of a case that requires investigation via e-mail. (Note: sometimes cases can be referred to you by Risk Management or other PSI- CRS users)
Using the link to the PSI- CRS in the e-mail, you can
1) Log in using your Level 2 password,
2) View the case that was referred (a “view only” version of the case will be displayed on the screen)
(Note: you can generate a pdf file of the case from the “view only” version. Just click the “Show PDF” button at the bottom left corner of the screen.)
3) Click on the Worklist from the navigation menu to access your list of referred cases and select a case for investigation.
4) Enter your case findings and then record your review decision.
c. If you determine there is a discrepancy with either the ICD-9-CM diagnosis and PoA coding, indicate this finding by selecting the corresponding radio button option, enter any comments and submit the results. If you identify and record a coding discrepancy, the case is sent to HIM for review and correction.
d. If there is no coding discrepancy, you must determine whether the complication of care was not preventable or potentially preventable and submit the results. The case is then referred to Risk Management for appropriate analysis and follow-up.
e. If the HIM coding expert disagrees with your assessment that there was a coding discrepancy, the case is sent to an arbitrator for resolution.
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