The Vanishing ECMO Exclusion

AHRQ’s Patient Safety Indicators (PSIs) are used in many healthcare quality programs as a way to measure safety incidents at hospitals. Each indicator looks at a different aspects of safety. Examples of PSIs are measures that look at pressure ulcers, operative hemorrhage / hematoma, accidental puncture / laceration and pulmonary embolism / deep vein thrombosis. The PSIs are based on evaluating combinations of ICD-10 diagnosis and procedure codes from claims data.

As part of the Hospital Compare website, CMS publicly releases each hospitals’ performance on individual PSIs and the composite PSI, PSI-90. PSI-90 is in many quality based programs, such as the Overall Rating (aka Stars), Value-Based Purchasing, and the Hospital Acquired Condition Reduction Program. Individual PSIs are used in ratings by many organizations, including US News & World Reports Best Hospitals Rankings, Leapfrog, and Vizient.

Needless to say, it is important for hospitals to perform well in PSIs.

As of October 2018, some hospitals may have noticed worse performance on one of the PSIs – and it’s all due to a minor change in coding.

The PSI in question is PSI 12 – Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate. (Click here for the AHRQ measure specification.) One of the exclusions from this measure is the use of extracorporeal membrane oxygenation (ECMO) for the care of a patient.

This exclusion stopped working on October 1, 2018 and its due to a change in ICD-10 rules.

For the last three years under ICD-10, ECMO patients have all received one common procedure code.

ICD-10 Procedure CodeDescription
5A15223Extracorporeal Membrane Oxygenation, Continuous

The current AHRQ specification, v2018, and all the software used to identify PSIs are written to find 5A15223 in the claim. However, that PSI exclusion isn’t working because the 5A15223 code has been removed from usable ICD-10-PCS codes.

Starting with Federal Fiscal Year 2019, the one ECMO code was broken into three new codes to increase specificity.

ICD-10 Procedure CodeDescription
5A1522FExtracorporeal Oxygenation, Membrane, Central
5A1522G Extracorporeal Oxygenation, Membrane, Peripheral Veno-arterial
5A1522H Extracorporeal Oxygenation, Membrane, Peripheral Veno-venous

Unfortunately, the AHRQ specification and any software based on that specification no longer recognizes ECMO as an exclusion from the PSI 12 measure for patients after October 1, 2018.

Compounding the issue is the fact that rates of PE/DVT are much higher in patients on ECMO than in the standard surgical population. Hospitals that perform this life-saving procedure are being unfairly judged compared to those they don’t have ECMO programs.

While this is likely to be fixed in a later update to the AHRQ PSI rules (and associated software), until it is, patients on ECMO are likely to be included inappropriately as a PSI 12 event.

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