Overall, administrative data have the advantage of being populated by professional coders that use a common set of practices and guidelines, which brings some uniformity to the data that may be lacking in clinical data abstracted from medical records or recorded in electronic medical records (EMR) systems.
The Quality Indicators software compiles hospital inpatient administrative data that provides demographics on the patient and the provider, diagnosis codes, procedure codes, and information about the admission, payer, and discharge. The Quality Indicators software has been maintained to be backwards compatible and validly handle ICD-9-CM diagnosis and procedure codes in effect from 1994.
The Quality Indicators measures are a constant work in progress. They are continually being revised in response to new research or validation efforts, NQF recommendations, or user feedback. If you have a question regarding a coding change, then consult the change logs for the relevant Quality Indicators PQI, IQI, PSI, PDI. The change log documents all coding changes that occur. Also consider the technical specifications and examine which cases match each denominator to determine why each case was flagged.
▲Although we have examined potential ways to exclude DNR or palliative care patients, we have not implemented this exclusion and do not plan to in the immediate future. The ability to accurately identify such patients is limited using administrative data. First, DNR codes are not consistently applied, are not available in most databases, and vary in definition (e.g., DNR on admission vs. DNR during admission).
Regarding palliative care, there is a code for encounter for palliative care. We have been provided with analyses from the University Hospital Consortium that demonstrate that at some hospitals this code is synonymous with death, while for others very few patients with this code die.
We do not rely on the V code for palliative care (V66.7) because it does not specifically identify hospice care, can be applied at any time during a hospitalization (e.g., several weeks or months after admission), and is not yet reliably reported. See AHA Coding Clinic for ICD-9-CM, 3Q 2008, Volume 25(32):13-14: "This code may be reported for any terminally ill patient who receives palliative care, regardless as to when the decision is made. There is no time limit or minimum for the use of this code assignment." See also AHA Coding Clinic for ICD-9-CM, 1Q 1998, Volume 15(1):11: "Terms such as comfort care, end-of-life care, and hospice care are all synonymous with palliative care. These, or similar terms, need to be written in the record to support the use of code V66.7."
In order for us to consider use of this code, the coding guidance will need to be clarified or 5th digits must be included. We encourage professional societies with interest in these codes to submit proposals to clarify the guidance and/or the creation of additional, more specific codes.
▲The denominator exclusion includes all of the codes in the numerator definition. For example, if any of the codes used in the numerator are in the principal diagnosis field, then the case is excluded from the denominator. Similarly, if any of the codes used in the numerator are in a secondary diagnosis field and are present on admission, then the case is excluded from the denominator. A patient meeting criteria for multiple measures will be included in each measure's denominator.
We list codes explicitly and not imply that additional digits are included. For example, the PQIs denote diagnosis codes as 3 or 4 digits, so we do not accept codes with 5 digits. The SAS® formats have the definitive list of codes if there is some question about a particular code.
Any indicator that uses a population denominator (from US Census) should use the patient FIPS code. Otherwise there might be cases in the numerator that are not included in the denominator.
▲Each year, DRG codes are updated-usually with new codes. The DRG version refers to the version in effect for a particular discharge record. The main purpose of DRG Version in the software is to distinguish CMS-DRG codes from Medicare Severity Diagnosis Related Group (MS-DRG) codes. Previous versions used discharge year/discharge quarter, where anything equal to or later than October 1, 2007 was considered MS-DRG. Not all hospitals had MS-DRG codes available after 2007/4 (i.e., discharge year/discharge quarter), so we changed the entry process to match HCUP where DRG versions 25-28 (as of October 2011) expect the DRG column data to be MS-DRG codes. Anything codes less than 25 (20-24) are considered CMS-DRG codes.
▲Conceptually, the rationale for the Low-Mortality DRG indicator is that the deaths that are flagged belong to DRGs with very low mortality rates (i.e., less than 0.5%). In other words, death is not an expected outcome for these DRGs. Cases that are flagged are considered never events (events that should not occur) like transfusion reaction and foreign body left in during procedure. Therefore, patients that belong to one DRG do not have a higher risk of death than patients in another DRG, and one might argue that risk adjustment is not appropriate. However, in the real world the lines between never events and potentially preventable events are not so clearly drawn. The mortality rate for some DRGs is higher than for other DRGs. In addition, users have expressed a preference for risk-adjustment and risk-adjustment was a requirement for NQF endorsement, so the indicator is in fact risk-adjusted.
▲Yes. A few of the indicators use E-code in the numerator, denominator or exclusion specifications. E-codes have different coding requirements than other ICD-9-CM codes, which require that a complication be coded only if it was unexpected and changed the course of care. Because national guidelines for E-codes do not require that a condition be an unexpected aspect of a procedure or disease in order to receive an additional code (i.e., an E-code), many minor and anticipated complications may be coded using these E-codes. Although several clinical panels have endorsed the concept of the indicator, in practice the types of cases identified are often not the type of complication originally envisioned by the panels during Quality Indicators measure development.
▲We do not support CPT (Current Procedural Terminology) codes for use with the AHRQ Quality Indicators that use inpatient administrative data, though we are considering their use in emergency department PSIs and PQIs.
▲The provider-level composite measure is the weighted average of the smoothed rates of a set of indicators. The other rates are not part of the composite measure. Area-level composites measures, however, are calculated in the same manner as normal indicators. The reliability-adjusted rates are the same as the smoothed rates. There is additional information in the composite user guides ( PQI, IQI, PSI, PDI.) An increase in the composite is interpreted as an increase in the observed rate of the hospital relative to the expected rate. Examining each indicator can help determine what is driving the overall rate.
▲Both of these indicators have discharge based denominators, rather than population denominators.
▲ Why isn’t 518.5 included in Postoperative Respiratory Failure?518.5 is a non-specific code, which includes traumatic respiratory failure, as well as respiratory distress, wet lung syndrome and idiopathic respiratory insufficiency for instance. We originally included this code in the software, but it was removed after chart review studies found it had a very high false positive rate.
However, we have since proposed changes to the ICD-9-CM system to increase the specificity of the codes and this proposal was discussed at the recent Coding and Maintenance Committee meeting (see page 30 of http://www.cdc.gov/nchs/data/icd9/TopicpacketforMarch2011_HA1.pdf). It is likely that this proposal or a very similar solution will be adopted and we will be able to further modify the indicator definition to capture more cases without sacrificing the specificity.
▲