HCPro, JustCoding Inpatient - 2015 Issue 21 (June)
Identify vulnerabilities related to Patient Safety Indicator12
June 3rd, 2015
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Article Overview
This final installment in a PSI 90 series examines PSI 12 and the types of documentation and coding issues that can affect hospital quality measurement and risk adjustment. It is aimed at coders, CDI specialists, and other hospital staff involved in claims-based reporting, EHR optimization, and quality improvement. The article also discusses broader operational ways to support better data capture through documentation workflows and interdepartmental collaboration.
Why This Topic Matters
PSI 12 is part of a CMS-linked quality framework that can influence reported performance and hospital evaluation. Understanding the article helps healthcare teams identify documentation and coding vulnerabilities that may affect measure results and support more complete clinical data capture.
Article Sections
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Introduction to PSI 12
Introduces PSI 12 and places it within the PSI 90 composite and hospital quality measurement context. It also notes the role of measure specifications and risk adjustment.
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PSI 12 inclusions
Summarizes the types of discharges included in the measure and the general documentation and coding concerns associated with those inclusions.
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Coding and documentation vulnerabilities for inclusions
Discusses broad documentation challenges related to identifying measure-triggering conditions and translating provider documentation into coded data.
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PSI 12 risk adjustment
Explains the role of comorbidities and risk adjustment variables in PSI 12 performance and describes categories that influence the measure.
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Documentation and coding vulnerabilities
Reviews how comorbidity capture affects risk adjustment and how coded data support validation, education, and workflow review.
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Leveraging the EHR
Describes how EHR functionality can be used to improve documentation quality, standardization, and diagnostic specificity.
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Identify the need for template changes
Outlines the general process of evaluating documentation templates and considering system changes that support better data capture.
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How to get involved
Covers the operational steps for submitting enhancement requests and engaging internal stakeholders in EHR improvement efforts.
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Find partners
Highlights organizational groups that may participate in documentation improvement and EHR optimization initiatives.
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Summary
Provides a closing overview of the article’s focus on documentation, coding, and claims-based quality outcomes.
What You Will Learn
- How PSI 12 fits into the PSI 90 composite and quality reporting environment
- The general categories of documentation and coding vulnerabilities discussed for PSI 12
- How risk adjustment and comorbidity capture affect measure performance
- Ways EHR design and workflow changes can support documentation improvement
- Which internal stakeholders may be involved in documentation optimization efforts
Who Should Read This
- Hospital coders
- Clinical documentation improvement (CDI) specialists
- HIM professionals
- Quality improvement staff
- Hospital revenue cycle teams
- EHR optimization and IT staff
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