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Has your CDI program shifted its focus for optimal PSI 15 performance?

Has your CDI program shifted its focus for optimal PSI 15 performance?

by Shannon Newell, RHIA, CCS, and AHIMA-approved ICD-10-CM/PCS trainer

The recent adoption of a refined version of the Patient Safety Indicator (PSI) 90 composite by the Agency forHealthcare Research and Quality (AHRQ) has a significant impact on what discharges are included in PSI 15 (Unrecognized Abdominopelvic Accidental Puncture Laceration Rate).

Your clinical documentation improvement (CDI) program has likely focused on this measure due to the well-established challenges associated with accurate reporting of procedure-related accidental puncture/lacerations. Given the changes to PSI 15, should your CDI team shift its focus to promote and support accurate data integrity for this measure? Let’s take a look.

A fundamental understanding of patient safety indicator measures

Optimal data integrity for PSIs requires that we have the appropriate clinical documentation and reported ICD-10 codes to accurately reflect the following:

  • The numerator: The numerator for PSI 15, also called the "outcome of interest," reports the actual number of cases which experienced the accidental puncture/laceration.
  • The denominator: The denominator for PSI 15, also called the "cohort," establishes the population which is screened to identify the outcome of interest.
  • Risk adjustment: Denominator comorbidities, which have a statistically demonstrated impact on the likelihood of a patient incurring the patient safety event. The risk adjustment methodology establishes the expected number of discharges with the outcomes of interest.


The inputs above?numerator, denominator, risk adjustment?are used to calculate our observed over expected performance. CMS compares our performance to that reported by other hospitals, and our reimbursement may be then impacted if we do not appear to manage patients well.

For example, in the Hospital Acquired Condition Reduction program, if our performance for PSI 90 does not meet established thresholds, then our Medicare fee-for-service reimbursement is reduced by 1% the next CMS fiscal year (October 1?September 30) for every claim we submit.


The new PSI 15?what counts?

The revised measure specifications for PSI 15 have altered the numerator (outcome of interest). The denominator, or cohort?which represents the population at risk?has also undergone a noteworthy change).

The revised numerator and denominator greatly narrow the pool of discharges screened for accidental punctures or lacerations as well as those flagged with outcomes of interest.

From a CDI perspective, the likelihood of incorrectly reporting accidental puncture or laceration for the discharges included in the newly defined measure is greatly diminished.


PSI 15: Are you focused on risk adjustment?

Given that our performance for PSI 15 is assessed using our observed over expected rate of procedure related accidental puncture or lacerations, the CDI team’s focus may be better spent on strengthening the capture of comorbidities relevant to risk adjustment.

The AHRQ risk adjustment methodology looks for multiple comorbidities to calculate the predicted likelihood of accidental punctures/lacerations for each discharge.

The revision to the discharges included in the narrowed cohort has also impacted which comorbidities affect risk adjustment. This makes sense given that these comorbidities must be clinically relevant to the numerator and denominator. The number of comorbid categories has been reduced from 13 to 11. Some of the categories remain the same, some have been deleted, and new ones have been added.



Keeping abreast of revisions to claims-based measures is an expanded responsibility for today’s CDI program. These measures impact both reimbursement and quality profiles. Positioned with this information, the CDI program can then shift efforts to promote and support clinical documentation capture and accurate reporting of codes associated with areas of the greatest vulnerability and impact.



Editor’s note:

Newell is the director of CDI quality initiatives for Enjoin. She has extensive operational and consulting expertise in coding and clinical documentation improvement, performance improvement, case management, and health information management. You can reach Newell at (704) 931-8537 or Opinions expressed are that of the author and do not represent HCPro or ACDIS. – Briefings on Coding Compliance Strategies