Wahiyda Harding MSA, RHIA, CCS

Education and Training Mentor

MedPartners –MPU Division

The new buzz in auditing – Quality reviews

To understand the concept behind quality reviews it is important to understand quality of care. The Center for Medicare and Medicaid Services (CMS) continues to refine the Medicare quality indicators and quality measures.

The World Health Organization (WHO) defines quality of care as “the extent to which health care services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable and people-centered”.

According to the Agency for Healthcare Research and Quality (AHRQ), “The Institute of Medicine defines health care quality as “the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

The goal of a quality review audit is to ensure that all documented diagnoses are captured and reported appropriately. The Severity of Illness (SOI) and Risk of Mortality (ROM) is calculated only for conditions that are present on admission (POA), i.e. diagnoses with a POA indicator of Y.  

By focusing on quality reviews, the auditor ensures all reportable codes are captured based on documentation and coding guidelines. When Patient Safety Indicators (PSIs) are identified, they are reviewed to decide whether they should be reported or excluded. It’s very important to be aware of diagnoses that may be excluded since PSIs will negatively affect a case.

To determine the true quality score, all conditions with a POA indicator of “N’ should be excluded and removed.  Hierarchical condition codes (HCC)) that are used for risk adjustment coding also impacts quality and can show the true acuity of the patient based on the codes reported.

Case scenario example- upon review of an elective admission for a left knee arthroplasty surgical case, J95.811 (acute post-procedural respiratory failure) is coded with a POA of “N (No)” which resulted in PSI 11 – post-operative respiratory failure, being reported and could negatively impact the case.  This PSI code assignment will be reviewed to ensure that the appropriate code is being assigned based on documentation and coding guidelines. Is the respiratory failure due to the surgery and/or did the physician document acute postoperative respiratory failure? If coded appropriately could this diagnosis be excluded based on the exclusion criteria for PSI 11?  AHRQ Quality Indicators™ (AHRQ QI™) ICD-10-CM/PCS Specification v2018 addresses this quality and coding measure: https://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V2018/TechSpecs/PSI_11_Postoperative_Respiratory_Failure_Rate.pdf

More facilities are now shifting from the traditional Diagnosis Related Grouper (DRG) prebill review to a Quality prebill review. The paradigm is shifting as CMS continues to focus on quality of care. CMS now publishes a facility star rating, with five stars being the highest. The Becker Hospital review, March 2019 edition, identified 293 hospitals with a five star rating.

Is your health care system ready to direct its auditing efforts to focus on quality of care to ensure that all documented diagnoses are captured and reported appropriately?  MedPartners has the expertise to find the solutions to assist you! 

Want to see how CMS rated YOUR facility?

Check out this most recent report here:


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