Reviewing for Inpatient Quality

This monthly blog will discuss all the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.

The Hospital Value-Based Purchasing (HVBP) Program has heightened hospital awareness of quality outcomes. Under this program, payments made under the Inpatient Prospective Payment System (IPPS) are based on the quality of care that was provided. Quality of care is recognized through the clinical documentation that supports accurate ICD code assignment. Thus, many clinical documentation improvement (CDI) programs are now evolving to support quality initiatives. Some of the drivers impacting quality outcomes within the inpatient setting are severity of illness (SOI), risk of mortality (ROM), hospital acquired conditions (HACs), patient safety indicators (PSIs), and core measures.

  • SOI and ROM are measured by a score that is determined using an algorithm calculation of the diagnoses and procedures that are coded. The score is divided into a subclassification of one of the following: 1 Minor, 2 Moderate, 3 Major, and 4 Extreme. This SOI score represents how sick the patient is and ROM represents the risk of death. It is important to assure diagnoses are documented to the highest level of specificity to achieve the appropriate SOI and ROM score.
  • HACs are preventable conditions that occur during a hospitalization. There are currently 14 categories of HACs. The Centers for Medicare and Medicaid Services (CMS) updates the list as they deem appropriate. It is crucial that the documentation identifies if diagnoses are present on admission or developed after admission. You can learn more about HACs at the CMS website link listed here,
  • Patient safety indicators (PSIs): PSIs are a set of indicators that identify hospital complications following procedures, childbirth, and surgeries. PSI 90 (Patient Safety and Adverse Events Composite) is a composite score of component indicators. PSI 90 will be changing from eight to 10 composite indicators. It is important to identify present on admission (POA) status and assure the correct principal diagnosis has been applied. You can learn more about the PSIs at the AHRQ website:
  • Core Measures: The Joint Commission works with CMS to align common measures that can be found within the Specification Manual for National Hospital Inpatient Quality Measures. Core measures are recognized standards of patient care. It is important that clinical documentation represent all the diagnoses and care provided to identify if these standards have been met. You can learn more about core measures at

For CDI programs that are making the transition to review and track quality impact, it is important to remember the scope of work that can be done with current productivity expectations. If this is added to the review process then productivity may need to be adjusted. It will take time to identity the quality risks and determine if the risk is identified accurately, coded incorrectly, or if the documentation reflects the correct outcome. Since this is a process that requires education on the quality initiatives, it may be worth looking into a new staff position that can just focus on quality impact.

Have any of you started to incorporate quality initiatives into the health record reviews? How did you go about incorporating this into the review process?


Tammy Combs, RN, MSN, CDIP, CCS, CCDS, is director and lead nurse planner of HIM Practice Excellence for AHIMA. She provides professional practice expertise to AHIMA members, the media, and outside organizations on clinical documentation improvement (CDI) practice issues. Combs authors material and provides support for AHIMA’s online CDI education platforms. She also serves as faculty for the AHIMA CDI Academies and CDIP Exam Preps, and is a technical advisor for AHIMA on CDI publications.

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